Kaneko and colleagues examined a cohort of 3380 patients from the STS database (2011 2013) who underwent elective isolated reoperative AVR, and they demonstrated a higher (but acceptable) operative mortality rate than that seen with initial AVR (4.6% versus 2.2%; P<0.0001) and relatively low complication This was true even among octogenarians who underwent reoperative AVR.3 In a cohort of 136 consecutive patients who underwent surgical correction for a non endocarditis-related aortic or mitral paravalvular leak (1986 2001), surgical correction of the paravalvular leak was associ- ated with acceptable operative mortality (6.6%) and morbidity rates.1 More recently, Shah and colleagues reported an operative mortality rate of 3% among 495 patients undergoing surgery for paravalvular leak,14 with higher risk associated with mitral than with aortic valve procedures (odds are consistent with the findings of Bouhout and who reported operative mortality rates of 8% among mitral valve, 3% among aor- tic valve, and 14% among double-valve patients in a total cohort of 190 patients undergoing sur- gery indicated for paravalvular leak. Estimates of operative risk for individual patients can be calcu- lated by using the STS risk calculator (http://risk- 2. Prosthetic valve deterioration can result in regurgi- tation attributable to leaflet calcification and non- coaptation or leaflet degeneration with a tear or perforation. Even in asymptomatic patients with severe prosthetic regurgitation, valve replacement is reasonable because of the risk of sudden clini- cal deterioration if further leaflet tearing occurs. IE should be excluded or concurrently treated. If a watchful waiting approach is taken in asymp- tomatic patients with severe prosthetic valve regurgitation, referral to a Comprehensive Heart Valve Center is prudent. 3. In some patients, operative risk is high, or surgery is not feasible. 