AVR indicates aortic valve replacement; CAD, coronary artery disease; CABG, coronary artery bypass graft; CT, computed tomography; LV, left ventricular; MR, mitral regurgitation; PCI, percutaneous coronary intervention; SYNTAX, Synergy Between Percutaneous Coronary Intervention With Taxus and Cardiac Surgery; and TAVI, transcatheter aortic valve implantation. CLINICAL STATEMENTS AND GUIDELINES those least amenable to percutaneous treatment. Subsets of patients shown to have superior free- dom from major adverse cardiac events include those with complex left main disease and those with a SYNTAX score >33.3 Accordingly, a surgical approach is reasonable in this subset of patients. Among SAVR patients, revascularization for those with significant CAD (>50% stenosis) has been shown to impact late risk of mortality favorably.4 14.1.2. Management of CAD in Patients Undergoing Valve Surgery Recommendations for Management of CAD in Patients Undergoing Valve Surgery Referenced studies that support the recommendations are summarized in Online Data Supplement 45. 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. 