Evidence Gaps and Future Directions for Patients With VHD Evidence Gaps Future Directions Identification of patients at risk and valve disease prevention (Stage A) Disease mechanisms Basic science to identify specific targets for medical therapy Rheumatic heart disease Primary and secondary prevention Calcific valve disease Identification of patients at risk Risk factor intervention Prevention of disease initiation Medical therapy for progressive valve disease (Stage B) Disease mechanisms Basic science to identify specific targets to slow or reverse disease progression Medical intervention Targeted therapy using advanced imaging endpoints to study disease mechanisms Ventricular and vascular interactions Dynamic interplay between valve disease severity and changes in ventricular anatomy and function Modulation of ventricular and vascular dysfunction in patients with VHD Optimal timing of intervention (Stage C) Improved measures of disease severity Validation of newer measures of LV size (eg, volumes instead of dimension) and function (eg, strain) for timing of intervention decisions. Evaluation of nonimaging parameters (serum markers and other novel approaches) Timing of intervention Timing of intervention in asymptomatic patients with valve regurgitation Intervention for asymptomatic severe AS Intervention for moderate AS with LV dysfunction Identification of patients with secondary MR who benefit from intervention Patient-centered research Involvement of patients in identifying research questions, study design, and definition of outcomes Inclusion of diverse patient groups Adequate representation of diverse patient populations in RCTs for VHD Decision aids Development and validation of improved decision aids for shared decision-making with patients Implementation and validation of decision algorithms for physicians and Heart Valve Teams Intervention options and long-term management (Stage D) Improved prosthetic valves Durability of TAVI valves Nonthrombogenic durable surgical and transcatheter valves Optimal antithrombotic therapy Alternatives to VKA anticoagulation for mechanical valves Management of anticoagulation during pregnancy Optimal antithrombotic therapy after TAVI Medical therapy after AVR Medical therapy to address ventricular and vascular function Optimal blood pressure targets after valve intervention Lower procedural risk Approaches to lower surgical morbidity and mortality rates Prevention of postoperative AF Noninvasive approaches for correction of valve dysfunction Prevention of complications Approaches to avoid need for permanent pacing after SAVR or TAVI Better prevention, diagnosis and treatment of endocarditis. 