For regurgi- tant lesions, calculation of regurgitant orifice area, vol- ume, and fraction is performed, when possible in the context of a multiparameter severity grade based on color Doppler imaging, continuous- and pulsed-wave Doppler recordings, and the presence or absence of distal flow reversals. Pulmonary systolic pressure also is estimated, along with qualitative evaluation of right ventricular (RV) size and function.7 In selected patients, additional testing, such as stress testing, TEE, cardiac catheterization, and CT or CMR imaging, might be indicated. However, both the performance and inter- pretation of these diagnostic tests require meticulous attention to detail, as well as expertise in cardiac imag- ing and evaluation of hemodynamics. Because echocar- diography remains the mainstay of the initial evaluation of all patients with VHD, it is recommended that the laboratory be an Intersocietal Accreditation Commis- sion (IAC) accredited program.8 Table 2. Applying Class of Recommendation and Level of Evidence to Clinical Strategies, Interventions, Treatments, or Diagnostic Testing in Patient Care (Updated May 2019)* CLINICAL STATEMENTS AND GUIDELINES 2.3.2. Diagnostic Testing: Changing Signs or Symptoms Patients with VHD should be instructed to promptly re- port any change in symptom status. The onset of symp- toms or a change in the physical examination should raise concern about the cardiac response to the valve lesion, necessitating a repeat TTE. A repeat comprehen- sive TTE study can determine whether symptoms are caused by progressive valve dysfunction, deterioration of the ventricular response to the volume or pressure overload, or another etiology. New signs on physical examination also warrant a repeat TTE.1 7 This requires that patients with known VHD have access to a primary care provider and a cardiovascular specialist. 2.3.3. Diagnostic Testing: Routine Follow-Up After initial evaluation of an asymptomatic patient with VHD, the clinician should continue regular follow-up with periodic examinations and TTE. 