AF indicates atrial fibrillation; MS, mitral stenosis; NOAC, non vitamin K oral anticoagulant; VHD, valvular heart disease; and VKA, vitamin K antagonist. CLINICAL STATEMENTS AND GUIDELINES bleeding in the dabigatran group. Until there is an explanation of why these adverse events occurred, there is insufficient evidence to support the use of NOACs for patients with mechanical heart valves.7 2.5. Evaluation of Surgical and Interventional Risk Recommendation for Evaluation of Surgical and Interventional Risk COR LOE Recommendation For patients with VHD for whom intervention is contemplated, individual risks should be calculated for specific surgical and/or transcatheter procedures, using online tools when available, and discussed before the procedure as a part of a shared decision-making process. Synopsis Risk assessment has become a foundational element of the preprocedural evaluation of patients with VHD for whom intervention to correct the valve lesion may be contemplated. Although there are limitations to the scoring systems used to estimate the risk of adverse outcomes, these estimates provide a useful point of reference against which procedural benefits can be weighed. Numerical estimates of risk are just one com- ponent of the multidisciplinary team (MDT) assessment process, and factors not routinely included in risk algo- rithms (eg, liver disease, porcelain aorta) add important dimensions. The availability of TAVI for treatment of symptomatic severe aortic stenosis (AS) across the sur- gical risk spectrum emphasizes the need to have discus- sions about younger age at implantation, valve durabil- ity, and the potential need for permanent pacemaker implantation. For young patients (eg, <65 years of age) who opt for a surgical bioprosthesis, strategies for se- quential procedures over a longer follow-up period (ie, valve-in-valve [ViV] TAVI versus reoperation) must be addressed. Recommendation-Specific Supportive Text 1. 