Synopsis The evaluation of patients with VHD who are undergo- ing noncardiac surgery is dependent on the type and Figure 20. Intervention for AF in patients with VHD. Colors correspond to Table 2. AF indicates atrial fibrillation; LA, left atrial, and VHD, valvular heart disease. CLINICAL STATEMENTS AND GUIDELINES severity of VHD, including 1) the presence or absence of symptoms, 2) the severity of VHD, 3) the risk of noncar- diac intervention, 4) the response of the LV and/or RV to the overload caused by VHD, and 5) the pulmonary artery systolic pressure. If the patient meets standard criteria for a cardiac intervention, it is prudent to de- fer elective noncardiac procedures and proceed to valve However, in emergency situations, noncardiac surgery may be necessary in the presence of uncorrected severe valve disease. All patients with severe VHD who are undergoing noncardiac surgery benefit from an evaluation by a Heart Team consisting of a cardiologist, cardiac anesthesiologist, and cardiac surgeons, in conjunction with the surgeon performing the procedure. In patients with severe VHD who are un- dergoing low-risk surgical procedures or in patients with mild to moderate VHD, noninvasive monitoring in con- sultation with a cardiovascular anesthesiologist may be all that is needed. 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. 