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15 Management during

non-cardiac surgery

In patients with significant VHD who undergo NCS, the risk of perioperative cardiovascular complications is increased and related to both the timing of the procedure (i.e. urgent vs non-urgent) and type of surgery (low, intermediate, or high risk), as well as patient-specific factors (type and severity of VHD, LV function, etc.).194,957–959 Detailed recommendations related to NCS are available in the 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery.960

15.1 Pre-operative evaluation

Echocardiography should be performed in all patients with VHD requiring NCS. Patient- and surgery-specific factors, along with risk calculators, can be used to guide the treatment strategy. Determination of functional capacity is a pivotal step for pre-operative risk assessment, measured either by the ability to perform activities in daily life or by exercise testing. Screening for frailty using validated tools is advisable.90 Decisions on pre- and perioperative management, surveillance, and continuation of chronic cardiovascular medical treatment should be taken after multidisciplinary discussion involving cardiologists, surgeons, and cardiac anaesthesiologists, as well as the team who will be in charge of the NCS. Patients receiving OAC treatment should be managed as described in Section 14.

15.2 Specific valve lesions

15.2.1. Aortic stenosis In patients with severe symptomatic AS, the treatment depends on the urgency and risk of NCS. If life-saving time-sensitive NCS is needed, it should be performed under careful haemodynamic monitoring avoiding rapid changes of volume status, with prompt treatment of arrhythmia regardless of AS severity. In cases of urgent high-risk NCS, TAVI or balloon aortic valvuloplasty should be considered in patients with critical AS prior to surgery, considering the risk of developing severe acute AR after

Recommendation Table 17 — Recommendations for the management of prosthetic valve dysfunction (see also Supplementary data online, Evidence Table 25)

Recommendations Classa Levelb

Haemolysis and paravalvular leak

It is recommended that the decision between transcatheter or surgical closure of clinically significant PVLs is based on Heart Team evaluation, including patient risk, leak morphology, and local expertise. I C Reoperation is recommended if a PVL is related to endocarditis, or causes haemolysis requiring repeated blood transfusion or leading to HF symptoms. I C Transcatheter closure should be considered for suitable PVLs with clinically significant regurgitation and/or haemolysis.940 IIa B Mechanical heart valve failure Reoperation is recommended in symptomatic patients with significant valve dysfunction not attributable to valve thrombosis. I C Biological heart valve failure Reintervention is recommended in symptomatic patients with significant valve dysfunction not attributable to valve thrombosis. I C Transcatheter, transfemoral valve-in-valve implantation in the aortic position should be considered in patients with significant valve dysfunction who are at intermediate or high surgical risk, and have suitable anatomical and prosthesis features, as assessed by the Heart Team.447,448,450,451,941 IIa B Transcatheter transvenous mitral or tricuspid valve-in-valve implantation should be considered in patients with significant valve dysfunction at intermediate or high surgical risk, if the anatomy is suitable.569,570,681,942–944 IIa B Reoperation should be considered in asymptomatic patients with significant prosthetic dysfunction, if surgical risk is low. IIa C Valve thrombosis TOE and/or 4D-CT are recommended in patients with suspected valve thrombosis to confirm the diagnosis.914,918,923,925,945–948 I C Mechanical heart valve thrombosis Heart Team evaluation is recommended in patients with acute HF (NYHA class III or IV) due to obstructive MHV thrombosis to determine appropriate management (repeat valve replacement or low-dose slow infusion fibrinolysis).923,926–929,931,949–954 I B Surgery should be considered for large (>10 mm) prosthetic thrombus complicated by embolism.913,932,933 IIa C Biological heart valve thrombosis OAC using VKA is recommended in BHV thrombosis before considering reintervention.867,934–937,955,956 I B OAC should be considered in patients with leaflet thickening and reduced leaflet motion leading to elevated gradients at least until resolution.918,920–922 IIa B © ESC/EACTS 2025

4D, four-dimensional; BHV, biological heart valve; CT, computed tomography; HF, heart failure; MHV, mechanical heart valve; NYHA, New York Heart Association; OAC, oral anticoagulation; PVL, paravalvular leak; TOE, transoesophageal echocardiography; VKA, vitamin K antagonist. aClass of recommendation. bLevel of evidence. Downloaded from academic.oup.com/eurheartj/article/46/44/4635/8234488 by guest on 07 October 2026