In patients with severe VHD who are undergoing elevated-risk noncardiac surgery, decisions should be made as to whether to proceed with the non- cardiac surgery and whether invasive hemodynamic or TEE imaging monitoring should be performed intraop- eratively and postoperatively in an intensive care setting. Recommendation-Specific Supportive Text 1. After a careful clinical evaluation and preopera- tive resting 12-lead ECG, patients being evalu- ated for noncardiac surgery who have known or suspected VHD of moderate or greater degree benefit from TTE.5 If there has been no change in clinical course, an echocardiogram within the past 12 months can be used. Most adverse events have occurred because the diagnosis of VHD was not known to the surgical team. The echocardio- graphic evaluation should quantify the severity of valve stenosis or regurgitation, calculate sys- tolic function, estimate diastolic function, evalu- ate LV size and myocardial structure, estimate RV size and function, and estimate pulmonary artery AS is present in 1% to 2% of all patients >65 years of age and 3% to 8% of all patients >75 years of age. Severe AS is asso- ciated with an increased risk during noncardiac surgery, depending on the specific degree of valve narrowing, LV systolic function, concurrent CAD, type of surgery, and other risk factors associated with surgery. Rheumatic MS may also be poorly tolerated during the altered hemodynamics of anesthesia and noncardiac surgery. Left-sided regurgitant lesions are better tolerated but still convey increased risk, particularly if the anesthesi- ologist and surgeon are unaware of the diagnosis or severity of valve disease. 