Tachycardia should be avoided because of the shortened diastolic LV filling time across the stenotic mitral valve, resulting in an increase in LA pressure.15 17 In asymptomatic patients with significant rheu- matic MS and with a pulmonary artery systolic pressure >50 mm Hg, the risk of elective inter- mediate- to high-risk noncardiac surgery is considerably higher, so these patients should be evaluated and treated as outlined in the rheumatic MS section (Section 6.2).6,7,18 3. In asymptomatic patients with significant MR and normal LV systolic function with a pulmo- nary artery systolic pressure <50 mm Hg who are undergoing elective noncardiac surgery, the overall hemodynamic goals are avoidance of both increased afterload and bradycardia by choosing the appropriate anesthetic scheme. Left-sided regurgitant lesions convey chronic LV volume overload and increased cardiac risk during noncardiac surgery but are better toler- ated than is stenotic valvular disease.11 Patients with significant MR undergoing noncardiac surgery had higher rates of postoperative HF and myocardial infarction than did controls The combination of neuraxial local anesthetics and opioids produces a favor- able systemic vasodilation for patients with regurgitant valve lesions. Patients with regur- gitant lesions will also do well with general anesthesia, which also lowers systemic vas- cular resistance. However, preload should be Invasive hemodynamic and/ or intraoperative TEE monitoring allows for continuous optimization of LV filling pressures and LV function during and after the opera- tive procedure. Patients should be admitted to an intensive monitoring setting for up to 24 to 72 hours after the procedure.15 In functional MR, especially in these patients for whom very careful attention to afterload control and fluid balance is crucial, anesthetic considerations should also include management of the under- lying heart disease (ie, ischemic heart disease, hypertrophic cardiomyopathy). 4. 