AVR (SAVR, TAVI) performed before elective elevated-risk noncardiac sur- gery in symptomatic patients with severe AS will prevent hemodynamic instability during, as well as after, noncardiac surgery.1 7 In AS patients who are undergoing noncardiac sur- gery, there is lack of data on the efficacy or safety of TAVI,8 but TAVI is a reasonable option to avoid delay of semi-urgent noncardiac sur- gery. In hemodynamically unstable patients at high to prohibitive surgical risk for AVR, bal- loon aortic valvuloplasty as a bridging strategy may be an option.9 11 Symptomatic patients with rheumatic MS (the pathophysiology and implications of rheumatic MS and AS are simi- lar) or patients with pulmonary artery systolic pressure >50 mm Hg benefit from valvular intervention before elective noncardiac surgery according to recommendations for rheumatic MS. Left-sided regurgitant lesions also convey increased cardiac risk during noncardiac sur- Although these lesions are generally better tolerated than stenotic valvular disease, in patients with MR and AR who are undergo- ing elective elevated-risk (ie, intermediate- or high-risk) noncardiac surgery and who meet standard indications for intervention, mitral or aortic valve surgery (repair or replacement) optimally should be performed before noncar- diac surgery. CLINICAL STATEMENTS AND GUIDELINES 15.3. Management of the Asymptomatic Patient Recommendations for Management of the Asymptomatic Patient With VHD Undergoing Noncardiac Surgery Referenced studies that support the recommendations are summarized in Online Data Supplement 47. 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. 