The m.3302A>G variant in MT-TL1 has been reported in four unrelated individuals with primary mitochondrial disease. Three individuals had features consistent with MELAS and the fourth had myopathy and respiratory failure. The heteroplasmy levels of the variant in affected individuals ranged from 45% to homoplasmic (PS4_moderate; PMIDs: 19370763, 8366098). This variant segregated with disease in one family as the proband and his mother harbored the variant at high heteroplasmy levels (values not provided) in fibroblasts and the variant was homoplasmic in muscle in the proband. An unaffected maternal aunt did not harbor the variant in her white blood cells (PP1; PMID: 8366098). There are no reports of de novo occurrences to our knowledge. Cybrid studies supported the functional impact of this variant as cybrids with the variant present at 98% heteroplasmy had a 6-fold reduction of respiration compared to those with 77% heteroplasmy showing no respiration defect (PS3_supporting; PMID: 17130166). The computational predictor MitoTIP suggests this variant is pathogenic (85.9 percentile) and HmtVAR predicts it to be pathogenic score of 0.85 (PP3). This variant is absent in the GenBank dataset, Helix dataset, and gnomAD v3.1.2 (PM2_supporting). In summary, this variant meets criteria to be classified as likely pathogenic for primary mitochondrial disease inherited in a mitochondrial manner. This classification was approved by the NICHD/NINDS U24 ClinGen Mitochondrial Disease Variant Curation Expert Panel on November 14, 2022. Mitochondrial DNA-specific ACMG/AMP criteria applied (PMID: 32906214): PS4_moderate, PP1, PS3_supporting, PM2_supporting, PP3.