Research is urgently needed on almost every aspect of VHD to ensure that patients who already have VHD receive optimal thera- py and to prevent VHD in those at risk. Approaches to improving outcomes in patients with VHD include 1) CLINICAL STATEMENTS AND GUIDELINES national and international registries and RCTs, 2) con- tinuous evaluation of outcomes data at each Compre- hensive and Primary Heart Valve Center, and 3) focus on patient-centric care, with involvement of the patient in the decision-making process (Table 26). More acces- sible quality and outcome data are also needed from Comprehensive Valve Centers to assist cardiologists and patients to make well-informed choices.1 3 Table 26. Evidence Gaps and Future Directions for Patients With VHD Evidence Gaps Future Directions Identification of patients at risk and valve disease prevention (Stage A) Disease mechanisms Basic science to identify specific targets for medical therapy Rheumatic heart disease Primary and secondary prevention Calcific valve disease Identification of patients at risk Risk factor intervention Prevention of disease initiation Medical therapy for progressive valve disease (Stage B) Disease mechanisms Basic science to identify specific targets to slow or reverse disease progression Medical intervention Targeted therapy using advanced imaging endpoints to study disease mechanisms Ventricular and vascular interactions Dynamic interplay between valve disease severity and changes in ventricular anatomy and function Modulation of ventricular and vascular dysfunction in patients with VHD Optimal timing of intervention (Stage C) Improved measures of disease severity Validation of newer measures of LV size (eg, volumes instead of dimension) and function (eg, strain) for timing of intervention decisions. 