1. [PREVIEW TEMPLATE] Abbott MitraClip

2. Abbott Srl Divisione Vascular (hereinafter “Abbott”) has requested permission to use the following: I, the undersigned, (NAME + FIRST NAME) understand that this case study will include anonymous patient testimonials and necessary anonymous recordings. The case study will be used by Abbott and/or its affiliates to provide additional insights regarding the use of MitraClip and published in a case book which will be used for educational purposes and distributed in Europe and Middle East countries. The printed document may include, among others, my name, occupational and professional description, phrases regarding me (or incidents or anecdotes concerning me) substantially as set forth in an attachment which is made a part of this release case study, picture, image, still photograph, article, promotional material or otherwise (the “Material”), which may be distributed among others. I hereby certify that all the data provided is accurate. No compensation will be due in exchange for my participation and/or appearance in the Material. I hereby consent to the processing by Abbott or any other company of the Abbott Group of Companies established in the European Economic Area or outside of any personal data obtained directly from me for any purpose related to the Material, such as described in this Consent form, in accordance with European and national privacy regulations. I hereby transfer to Abbott with full warranty any and all intellectual property rights (including existing and future copyright and all similar rights), if existing, on the Material, including all rights to changes, revisions, amendments, alterations and adaptations which have been made or at any time in the future will be made, and I acknowledge that all rights related to the Material belong to Abbott within the limits determined by law. Abbott, its affiliates and other third parties designated by Abbott may, in accordance with the rights in the Material transferred by me, use and reuse all existing and new media, including my portrait, image, name and appearance, possibly modified by Abbott, throughout the world and with no time restrictions, for marketing and promotion or for Abbott’s reasonable business objectives. I hereby finally and irrevocably waive any moral rights or similar rights which I may have in the world with regard to the Material, on the basis of European and/or national laws related thereto. Abbott is not required in whole or in part, to use the Material for any purpose whatsoever. All decisions by Abbott concerning the selection of the Material are final and I agree not to challenge or to appeal these decisions. Therefore, I hereby grant Abbott, its successors, assignees and anyone acting under its authority or permission the right to make full use of the Material at no cost to Abbott, where appropriate, and to use the Material for internal or external purposes throughout the world and reproduce the Material in any form or manner. Consent and Release Form Full Name 1: Full Name 2: Full Name 3: Full Name 4: Full Name 5: Full Name 6: Residence/Hospital: Address: Telephone: E-Mail: Date:

3. Implanting Team HOSPITAL NAME: Interventional Cardiologist: Clinical Cardiologist: Echocardiographer: Cardiac Surgeon: Cardiac Anesthesiologist: Other:

4. Case Title Case Title: Examples: TAVI and MitraClip, CRT non-responder, Patient withdrawn from transplant list, Patient was treated with local anesthesia, 5 clips, After surgery, terminal HF, Mitraclip and LAA with TEE and ICE, etc. Case Summary Case summary: Examples: “ICE was used during the case during the following MitraClip procedural steps”, “The summary of anaesthesiological protocol for local anaesthesia was: …” “The heart was stopped with adenosine to manage grasping the leaflets”

5. Patient profile Age & Gender: Relevant clinical history: (co-morbidities, surgery, transplant etc.) Relevant previous treatment(s) for mitral regurgitation: (100 words max.) Provide the background of the case study by highlighting the main reasons behind this situation, such as patient history, previous examinations, signs and symptoms.

6. Patient profile The reason why this patient was selected to have a percutaneous mitral valve repair: (100 words max.)

7. Basal Clinical Parameters Expand on the background of the case study by providing additional clinical results ADD HERE YOUR CONTENTS

8. MitraClip Procedure Overview Provide relevant technical information and describe if any problems encountered and how they were resolved. Include high resolution images if available where appropriate. Date of the case: Procedure description and technical challenges:

9. Outcomes and benefits Provide follow-up, e.g. percentage of improvements of signs and symptoms. Within 24: Within 3 days: 3 months follow-up (if available): Last appointment:

10. Phyisician’s overall assessments Describe the positive aspects of the device implementation and how it improved this patient's quality of life. ADD HERE YOUR CONTENTS

11. Significant images Provide one image (echo, angio…) that best represents the procedural success. Then provide pre and post procedure LVOT and IC or X-Plane / MultiD and 3D, if available. ADD HERE YOUR CONTENTS