COR LOE Recommendations In patients with symptoms of angina, objective evidence of ischemia, decreased LV systolic function, history of CAD, or coronary risk factors (including men >40 years of age and postmenopausal women), invasive coronary angiography is indicated before valve In patients with chronic severe secondary MR, invasive coronary angiography should be performed as part of the evaluation.9 11 In selected patients with a low to intermediate pretest probability of CAD, contrast-enhanced coronary CT angiography is reasonable to exclude the presence of significant obstructive In patients undergoing valve repair or replacement with significant proximal CAD ( 70% reduction in luminal diameter in major coronary arteries or 50% reduction in luminal diameter in the left main coronary artery and/or physiologically significance), CABG is reasonable for selective patients.19,20 Synopsis Coronary imaging in the setting of VHD defines anat- omy that may be at risk during surgery or interven- tion. Given their similar demographic profiles, CAD and VHD frequently coexist, and in the case of sec- ondary MR they have a pathophysiological link. Re- vascularization, in turn, can impact periprocedural risk or long-term outcome. In the case of secondary MR, revascularization may positively impact the valve dis- ease via reverse remodeling of the LV. In the surgical setting, where repeat intervention is at high cost to the patient, efforts are typically made to correct all surgically correctable disease present at the index op- eration. Accordingly, an aggressive approach to revas- cularization is appropriate. In the setting of percutane- ous interventions, however, the option of sequential interventions with interval tests of improvement may be appropriate. In either case, less invasive imaging via contrast-enhanced coronary CT angiography is in- creasingly adopted. Recommendation-Specific Supportive Text 1. 