Patients with severe AS who are at high to prohibi- tive surgical risk are best served by TAVI. As noted previously, primary MR may not improve after If symptoms persist after TAVI and if there is suitable anatomy, percutaneous mitral repair can be performed, which can reduce MR and improve For patients with AS who have secondary MR, the fate of MR after SAVR or TAVI is uncertain.2 5,7 10 Although secondary MR is more likely to improve after AVR than is MR attributable to primary mitral valve disease, secondary MR does not improve or may even worsen after AVR in many cases.7 10 The mechanism by which reduction in LV pressure after CLINICAL STATEMENTS AND GUIDELINES AVR does not reduce secondary MR is unknown. With SAVR, the mitral valve can be inspected and addressed, unlike with TAVI, where the mitral valve is left untreated. An alternative approach to patients with AS and secondary MR is to perform TAVI first, and if symptoms remain with persistent severe MR, mitral TEER can be performed if there is suitable anatomy.6 The transcatheter approach would be preferred if the patient is at high to pro- hibitive surgical risk. 10.2.3. Intervention for Mixed MS and MR Mixed MS and MR often occurs in patients with rheu- matic valve disease. Occasionally, mixed MS/MR can oc- cur in patients with severe mitral annular calcification. Asymptomatic mixed disease may be benign because MS protects the LV from the severe volume overload of pure MR. However, if symptoms attributable to mixed mitral disease occur, they are likely because of increased LA pressure from combined increased LA inflow from MR and obstruction to outflow from the LA. 