The decision about whether to proceed with TAVI ver- sus SAVR is discussed in Section 3.2.4.2. 2. For patients with mixed moderate AS/AR who have developed LV dysfunction, as evidenced by an LVEF of <50%, and who have no other reason for LV dysfunction, valve disease is presumed to be the cause. In such patients, SAVR is indicated.1,2 10.2.2. Intervention for Mixed AS and MR Patients with combined AS and MR present a dif- ficult and complex decision-making process. There are many potential different scenarios and nuances involved to arrive at the optimal approach for an in- dividual patient, which needs to be made by an MDT with shared decision-making with the patient. Over- all, patients with severe AS and severe primary MR are best treated with SAVR and mitral valve surgery unless the surgical risk is high or prohibitive. If there is a high or prohibitive surgical risk, a staged procedure, with TAVI followed by mitral TEER, can be effective. If there is severe AS and severe secondary MR, either SAVR and mitral valve surgery or a staged approach with TAVI followed by mitral TEER are options. Be- cause there are limited data to support COR, the writ- ing committee has created a table that provides the reader with a perspective on possible interventions in these complex patients (Table 21). Evaluating the short- and long-term outcomes of these approaches will be important. These proposed procedures are based on the following: Many patients with AS also have significant MR that is attributable to either organic (primary) causes or LV remodeling (secondary MR). AVR for AS reduces LV pressure, thereby reducing the pressure gradi- ent that propels volume across the incompetent mitral valve. 