Heart Valve Centers, in the context of an inte- grated multi-institutional model of care for patients with VHD, allow optimization of patient outcomes through improved decision-making and matching of patients to providers with appropriate expertise, expe- rience, and resources.12 Primary and Comprehensive Heart Valve Centers are defined by their offerings and expertise in the management of patients with VHD12 (Table 11). Table 9. Examples of Procedure-Specific Risk Factors for Interventions Not Incorporated Into Existing Risk Scores SAVR TAVI Surgical Mitral Valve Repair or Replacement TEER Technical or anatomic Prior mediastinal radiation Aorto-iliac occlusive disease precluding transfemoral approach Prior sternotomy Multivalve disease Ascending aortic calcification (porcelain aorta may be prohibitive) Aortic arch atherosclerosis (protuberant lesions) Severe MR or TR Low-lying coronary arteries Basal septal hypertrophy Valve morphology (eg, bicuspid or unicuspid valve) Extensive LV outflow tract calcification Prior mediastinal radiation Ascending aortic calcification (porcelain aorta may be prohibitive) Valve morphology (eg, thickening, perforations, clefts, calcification, and stenosis) Prior mitral valve surgery Comorbidities Severe COPD or home oxygen therapy Pulmonary hypertension Severe RV dysfunction Hepatic dysfunction Frailty* Severe COPD or home oxygen therapy Pulmonary hypertension Severe RV dysfunction Hepatic dysfunction Frailty* Severe COPD or home oxygen therapy Pulmonary hypertension Hepatic dysfunction Frailty* Severe COPD or home oxygen therapy Pulmonary hypertension Hepatic dysfunction Frailty* Futility STS score >15 Life expectancy <1 y Poor candidate for rehabilitation STS score >15 Life expectancy <1 y Poor candidate for rehabilitation STS score >15 Life expectancy <1 y Poor candidate for rehabilitation STS score >15 Life expectancy <1 y Poor candidate for rehabilitation *Validated frailty scores include the Katz Activities of Daily Living Score.10,34,35 COPD indicates chronic obstructive pulmonary disease; MR, mitral regurgitation; RV, right ventricular; SAVR, surgical aortic valve replacement; STS, Society of Thoracic Surgeons; TAVI, transcatheter aortic valve implantation; TEER, transcatheter edge-to-edge repair; and TR, tricuspid regurgitation. 