Unadjusted mortality rates for isolated tricuspid valve surgery have therefore exceeded those reported for isolated aortic or mitral valve surgery, and this trend has been even more pronounced for reoperative tri- cuspid surgery late after left-sided valve surgery.1,2,39 This high reoperative mortality rate is likely related to the advanced nature of RV failure encountered at the time of the second procedure, residual pulmo- nary hypertension, LV dysfunction, and other valve abnormalities. The hazards imposed by reoperation have influenced decision-making for initial repair of functional TR at the time of left-sided valve surgery in an attempt to prevent the development of severe TR later after the left-sided valve surgery. However, if there is no significant pulmonary hypertension or severe RV systolic dysfunction, operation for severe symptomatic isolated TR years after surgery for left- sided disease may improve symptoms of right-sided HF, if done before the onset of severe RV dysfunc- tion or end-organ damage with either hepatic or 9. PULMONIC VALVE DISEASE See guidelines for the management of adults with con- genital heart disease.1 10. MIXED VALVE DISEASE 10.1. Diagnosis of Mixed VHD Recommendations for Diagnosis and Follow-Up of Patients With Mixed Valve Disease COR LOE Recommendations For patients with mixed valve disease, TTE is recommended to assess the etiology, severity, and pathophysiological impact. In patients with ambiguous symptoms that are suspected to be attributable to mixed mitral valve disease, further assessment of filling pressure by using biomarkers or invasive hemodynamic measurements at rest or with exercise is reasonable. Synopsis Mixed valve disease is either 1) stenosis and regurgita- tion of a single valve or 2) stenosis or regurgitation of 2 separate valves. 