COR LOE Recommendations In asymptomatic patients with moderate or greater degrees of AS and normal LV systolic function, it is reasonable to perform elective In asymptomatic patients with moderate or greater degrees of rheumatic MS with less than severe pulmonary hypertension (pulmonary artery systolic pressure <50 mmHg), it is reasonable to perform elective noncardiac surgery. In asymptomatic patients with moderate or greater degrees of MR and normal LV systolic function with less than severe pulmonary hypertension (pulmonary artery systolic pressure <50 mmHg), it is reasonable to perform elective noncardiac surgery.4 7 In asymptomatic patients with moderate or greater degrees of AR and normal LV systolic function, it is reasonable to perform elective Synopsis In asymptomatic patients with significant VHD who do not meet standard criteria for intervention, the risk as- sociated with the noncardiac procedure can be mini- mized by choosing an anesthetic approach that is ap- propriate to the valve lesion and ensuring a higher level of intraoperative (and perioperative) monitoring, taking into account the underlying valvular abnormality, its ef- fect on LV function, and comorbidities. In patients with VHD, the cardiovascular risk of noncardiac surgery is also impacted by other cardiovascular conditions, such as LV and RV dysfunction, CAD, pulmonary hyperten- sion, and peripheral artery disease. In patients with moderate or greater degrees of AS, the hemodynamic effects of anesthesia and surgery are poorly tolerated; predictors of adverse outcomes include severity of AS, coexisting MR, pulmonary hypertension, and CAD. However, these comorbidities also increase the risk of AVR. Data are limited, but the risk benefit ratio con- tinues to favor managing asymptomatic patients with severe AS who are undergoing noncardiac surgery with hemodynamic monitoring and optimization of load- ing conditions, rather than considering prophylactic AVR. 