Recommendations for Intervention Referenced studies that support the recommendations are summarized in Online Data Supplement 41. COR LOE Recommendations In patients with intractable hemolysis or HF attributable to prosthetic transvalvular or paravalvular leak, surgery is recommended unless surgical risk is high or prohibitive.1 4 In asymptomatic patients with severe prosthetic regurgitation and low operative risk, surgery is reasonable.1 4 In patients with prosthetic paravalvular regurgitation with the following: 1) either intractable hemolysis or NYHA class III or IV symptoms and 2) who are at high or prohibitive surgical risk and 3) have anatomic features suitable for catheter-based therapy, percutaneous repair of paravalvular leak is reasonable when performed at a Comprehensive Valve Center.5 9 For patients with severe HF symptoms caused by bioprosthetic valve regurgitation who are at high to prohibitive surgical risk, a transcatheter ViV procedure is reasonable when performed at a Comprehensive Valve Center.10 12 Synopsis Prosthetic valve degeneration can result in regurgitation attributable to leaflet calcification and noncoaptation or leaflet degeneration with a tear or perforation. Acute or chronic severe regurgitation may result in HF symp- toms and signs. Paravalvular leak may result in hemoly- sis with symptoms attributable to anemia and HF. New paravalvular leak late after valve implantation raises the concern for IE, which should be excluded because the presence of infection would require antibiotic treat- ment before surgical therapy and would be a contrain- dication to transcatheter therapy. Symptomatic patients with paravalvular leak around a prosthetic valve are best managed by surgery, with percutaneous closure of the leak if the patient is at high or prohibitive surgical risk. Symptomatic patients with bioprosthetic valve regurgi- tation are best managed by surgery, with a transcath- eter ViV procedure if the patient is at high or prohibitive risk. 