The MDT is an established feature of heart valve and has been formally endorsed by the ACC, the American Society of Echocardiography, the Society for Cardiovascular Angiography and Interventions, the American Association for Thoracic Surgery, and the STS.12 Key members of the MDT include cardiologists with subspecialty expertise in the clinical evaluation of patients with VHD, as well as specialists in advanced cardiovas- cular imaging. For the evaluation of the patient with secondary mitral regurgitation (MR) and tri- cuspid regurgitation (TR), a specialist in HF also is included. Interventional cardiologists with training and expertise in VHD and surgeons experienced in the treatment of VHD anchor the MDT. Other team members include cardiovascular nurses, cardiovas- cular anesthesiologists, and intensivists involved in periprocedural care. Finally, the engagement of the primary clinical cardiologist and patient is of critical importance. The MDT facilitates presenta- tion of all appropriate options for medical, inter- ventional, and surgical treatment to the patient in a balanced manner, using tools and techniques for shared decision-making in which patient prefer- ences are considered. 2. Decision-making is particularly challenging for the asymptomatic VHD patient, for whom the risks of operative mortality and perioperative morbidity must be very low and the chances of a successful and durable surgical outcome very high. There is a substantial body of literature to support a relationship between institutional vol- ume and mortality rate for many cardiovascular procedures, including SAVR,1 5 and surgi- cal mitral valve repair.7 11 Consideration should be given to consultation with or referral to a Primary or Comprehensive Heart Valve Center for asymp- tomatic patients with severe VHD. 