Patients should be admitted to an intensive monitoring setting for up to 24 to 72 hours after the procedure.15 In functional MR, especially in these patients for whom very careful attention to afterload control and fluid balance is crucial, anesthetic considerations should also include management of the under- lying heart disease (ie, ischemic heart disease, hypertrophic cardiomyopathy). 4. Patients with severe AR are prone to hemody- namic instability because of the detrimental effects of increased volume on myocardial wall stress. The perioperative stress associated with noncardiac surgery may lead to hypotension, arrhythmias, HF, or even death. Patients with sig- nificant AR undergoing noncardiac surgery had a higher in-hospital mortality rate and higher mor- bidity rate, including postoperative myocardial infarction, stroke, pulmonary edema, intubation >24 hours, and major arrhythmias, than those of case-matched controls without AR. Decreased LV systolic function, elevated serum creatinine >2 mg/dL, and intermediate- to high-risk non- cardiac surgery were predictors of higher risk of cardiopulmonary complications and death.8 Avoid bradycardia when AR is present because of the increase in total diastolic time. These patients are monitored with invasive systemic arterial and venous catheters and/or TEE and are admitted postoperatively to an intensive moni- toring setting. 16. EVIDENCE GAPS AND FUTURE DIRECTIONS Many recommendations for the evaluation and man- agement of VHD continue to be based on clinical ex- perience and observational studies, with prospective RCTs limited mostly to new devices. We recommend that research on valve disease span the spectrum from basic science to prospective randomized trials, includ- ing medical therapy, and that studies focus on each stage of the disease process, from the patient at risk to the patient with end-stage disease. 