Clinical trials have identified anatomic consid- erations, detectable by TEE, that can identify patients with secondary MR who have a valve morphology amenable to TEER. In the COAPT (Cardiovascular Outcomes Assessment of the MitraClip Percutaneous Therapy for Heart Failure Patients with Functional Mitral Regurgitation) trial of patients with secondary MR and HF, exclusion criteria included vertical coaptation length <2 mm in valves with leaflet tethering, evidence of calci- fication in the grasping area of the A2 or P2 scal- lops, presence of a significant cleft of A2 or P2 scallops, and lack of both primary and secondary chordal support. These are similar criteria to the earlier EVEREST trial. TEE is standard preproce- dural imaging to determine suitability for TEER.3 8 4. During mitral TEER, TEE assists in guiding posi- tioning of the clip(s), assessing success of the procedure, determining whether more than a single clip is necessary to reduce MR, and assur- ing that the clip(s) has not created MS.4,7,9 13 CLINICAL STATEMENTS AND GUIDELINES 7.3.3. Medical Therapy Recommendations for Medical Therapy for Secondary MR Referenced studies that support the recommendations are summarized in Online Data Supplement 31. COR LOE Recommendations Patients with chronic severe secondary MR (Stages C and D) and HF with reduced LVEF should receive standard GDMT for HF, including ACE inhibitors, ARBs, beta blockers, aldosterone antagonists, and/or sacubitril/valsartan, and biventricular pacing as indicated.1 11 In patients with chronic severe secondary MR and HF with reduced LVEF, a cardiologist expert in the management of patients with HF and LV systolic dysfunction should be the primary MDT member responsible for implementing and monitoring optimal Synopsis GDMT for HF with reduced LVEF in patients with se- vere secondary MR should be provided, in conjunc- tion with a cardiology expert, in the management of HF. Recommendation-Specific Supportive Text 1. 