Background <p>There is little evidence regarding mitral transcatheter edge-to-edge repair (TEER) in the setting of severe pulmonary hypertension (PH), defined as an estimated pulmonary arterial systolic pressure (PASP) &gt; 70 mmHg on echocardiography. We sought to explore the prevalence of, and correlates and postprocedural outcomes associated with, severe PH in patients undergoing mitral TEER.</p> Methods <p>We retrospectively evaluated a single-center registry of isolated, first-time interventions as a function of severe PH presence at baseline. Outcomes included all-cause mortality, heart failure (HF) hospitalizations, and the persistence of significant mitral regurgitation (MR) and functional impairment during the first postprocedural year.</p> Results <p>A total of 1,182 individuals qualified for analysis. Of them, 100 (8.5%) had severe PH, demonstrating a median PASP of 78 (interquartile range, 75–85) mmHg. Compared to subjects free of severe PH, the former exhibited a higher interventional risk, a greater burden of comorbidities, and more severe MR and cardiac dysfunction, and were more likely to undergo an urgent procedure. General interventional features were unaffected by severe PH status, leading in both groups to a high (&gt; 97%) technical success rate and, ultimately, significant improvements in PASP, MR grade and functional capacity. Severe PH was associated with worse residual MR in the total cohort – but not within a 187-patient, propensity score matched sub-cohort. In either, it did not correlate with the rate, cumulative incidence, and risk of mortality and/or HF hospitalizations.</p> Conclusion <p>In our experience, severe PH preceding mitral TEER identified higher-risk patients but was unrelated to procedural feasibility, safety, or efficacy.</p> Graphical Abstract <p></p>