OBJECTIVE The aim of this study was to compare clinical outcomes of transcatheter and surgical mitral valve repair (SMVr) in primary mitral regurgitation (MR) and MR with heart failure with reduced ejection fraction (HFrEF). METHODS In this retrospective cohort study, we used the Nationwide Readmission Database to identify primary MR and MR with HFrEF patients who underwent transcatheter or SMVr from 2016 to 2019. A propensity score with 1:1 matching was applied. The primary outcome was a cumulative event rate of major adverse cardiovascular events (MACE), which was a composite of all-cause mortality, myocardial infarction, stroke, heart failure, cardiac arrest and mitral valve replacement. Other important secondary outcome was in-hospital mortality. RESULTS After propensity score matching, 2187 matched pairs were found in the primary MR cohort and 2178 matched pairs were found in the MR-HFrEF cohort. Transcatheter mitral valve repair (TMVr) had significantly higher medium-term MACE compared with SMVr in both cohorts (primary MR: hazard ratio: 1.73, 95% confidence interval: 1.33-2.26, P ≤ 0.001; MR-HFrEF: hazard ratio: 2.00, 95% confidence interval: 1.58-2.54, P ≤ 0.001). TMVr showed similar in-hospital mortality in both cohorts. CONCLUSIONS Although TMVr showed better short-term outcomes, it had significantly higher medium-term MACE than SMVr in both cohorts. Thus, shared decision-making should be performed for TMVr after discussing the benefits and risks in patients who can undergo SMVr.