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............................................................................................................................................................................. 12 Management during non- cardiac surgery Cardiovascular morbidity and mortality are increased in patients with VHD who undergo NCS. Symptomatic severe aortic stenosis or mitral stenosis may require valve replacement or percutaneous intervention before NCS. A detailed description of recommendations in the setting is available in specific ESC Guidelines.489 12.1 Preoperative evaluation Patient and surgical specific factors dictate the strategy.489,548,549 The cardiologist provides recommendations on pre- and perioperative management, surveillance, and continuation of chronic cardiovascular medical treatment. Echocardiography should be performed in any patient with VHD requiring NCS. Determination of functional capacity is a pivotal step in preoperative risk assessment, measured either by ability to perform activities in daily life or by exercise test. The decision for management should be taken after multidisciplinary discussion involving cardiologists, surgeons, and cardiac anaesthesiologists, as well as the team who will be in charge of NCS. Patients receiving anticoagulation treatment should be managed as discussed in section 11. 12.2 Specific valve lesions 12.2.1 Aortic stenosis In patients with severe aortic stenosis, urgent NCS should be performed under careful haemodynamic monitoring. In case of high risk of NCS, balloon valvuloplasty may be considered before NCS.549 Management related to elective NCS depends on the presence of symptoms and the type of surgery.489,549553 In symptomatic patients, aortic valve procedure should be considered before NCS. The type of procedure, TAVI or SAVR, is decided by the Heart Team. In asymptomatic patients, elective NCS, if at low to moderate risk, can be performed safely, albeit with a risk of worsening heart failure.489,552,553 If NCS implies large volume shifts, aortic valve procedure (TAVI or SAVR) should be considered first according to the Heart Team’s decision (Figure 11). 12.2.2 Mitral stenosis NCS can be performed safely in patients with non-significant mitral stenosis (valve area >1.5 cm2) and in asymptomatic patients with significant mitral stenosis and an SPAP <50 mmHg. In symptomatic patients or in patients with SPAP >50 mmHg, correction of mitral stenosis, by means of PMC whenever possible, should be attempted before NCS if it is high risk. 12.2.3 Aortic and mitral regurgitation NCS can be performed safely in asymptomatic patients with severe mitral regurgitation or aortic regurgitation and preserved LV function. The presence of symptoms or LV dysfunction should lead to consideration of valvular surgery, but this is seldom needed before NCS. If LV dysfunction is severe (ejection fraction <30%) and/or SPAP is >50/60 mmHg, NCS should be performed only if strictly necessary and after optimization of medical therapy for heart failure. 12.3 Perioperative monitoring Heart rate control (particularly in mitral stenosis) and careful fluid management (particularly in aortic stenosis) are needed. TOE monitoring may be considered. 13 Management during pregnancy Detailed guidelines on the management of cardiovascular disease during pregnancy are available in another document.554 The decision for Surgery should be considered for large (>10 mm) non-obstructive prosthetic thrombus complicated by embolism. IIa C Bioprosthetic thrombosis Anticoagulation using a VKA and/or UFH is recommended in bioprosthetic valve thrombosis before considering re-intervention. I C Anticoagulation should be considered in patients with leaflet thickening and reduced leaflet motion leading to elevated gradients, at least until resolution.541,546 IIa B Haemolysis and paravalvular leak Reoperation is recommended if a paravalvular leak is related to endocarditis or causes haemolysis requiring repeated blood transfusions or leading to severe heart failure symptoms. I C Transcatheter closure should be considered for suitable paravalvular leaks with clinically significant regurgitation and/or haemolysis in patients at high or prohibitive surgical risk.547 IIa B Decision on transcatheter or surgical closure of clinically significant paravalvular leaks should be considered based on patient risk status, leak morphology, and local expertise. IIa C Bioprosthetic failure Reoperation is recommended in symptomatic patients with a significant increase in transprosthetic gradient (after exclusion of valve thrombosis) or severe regurgitation. I C Transcatheter, transfemoral valve-in-valve implantation in the aortic position should be considered by the Heart Team depending on anatomic considerations, features of the prosthesis, and in patients who are at high operative risk or inoperable.529 IIa B Transcatheter valve-in-valve implantation in the mitral and tricuspid position may be considered in selected patients at high risk for surgical reintervention.382,531,532 IIb B Reoperation should be considered in asymptomatic patients with significant prosthetic dysfunction if reoperation is low risk. IIa C UFH = unfractionated heparin; VKA = vitamin K antagonist. aClass of recommendation. bLevel of evidence. ESC/EACTS 2021 Downloaded from academic.oup.com/eurheartj/article/43/7/561/6358470 by guest on 07 October 2026