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balloon aortic valvuloplasty.194,961 Urgent low- and intermediate-risk NCS can be performed relatively safely in patients with severe AS.962 Patients in whom NCS can be deferred (i.e. non-urgent NCS) should undergo pre-operative Heart Team evaluation to determine whether SAVR or TAVI is preferable. TAVI may be preferred to SAVR if faster recovery plays a role, particularly in elderly patients in whom complex or high-risk NCS is planned.963 The treatment of asymptomatic patients with severe AS should be individualized (Figure 21).964

15.2.2 Mitral stenosis

Heart rate and fluid balance should be controlled to prevent pulmonary oedema during NCS and arterial vasodilators should be avoided. Non-cardiac surgery is safe in patients with an MVA of >1.5 cm2, and in asymptomatic patients with MVA ≤1.5 cm2 and SPAP of <50 mmHg. Symptomatic patients or those with SPAP of >50 mmHg should undergo PMC or other appropriate valve intervention before high-risk NCS, if possible.965,966 Asymptomatic patients with MVA ≤1.5 cm2 can undergo low-to-moderate-risk NCS under careful monitoring, especially if PMC is unsuitable. Multidisciplinary management is advised for patients with significant MS who are ineligible for valve intervention.

15.2.3 Aortic and mitral regurgitation

Non-cardiac surgery can usually be performed safely in asymptomatic patients with severe MR or AR and preserved LV function. If NCS is urgent, patients should undergo surgery under strict haemodynamic monitoring, regardless of symptom status. In cases of elective (non-urgent) NCS in patients with severe ventricular SMR, medical therapy should be optimized. If symptoms persist and NCS is intermediate or high risk, TEER should be considered after Heart Team discussion based on clinical

Patient with severe AS requiring NCS

LOW-MODERATE

Urgent NCS

HIGH

HIGH

HIGH

LOW

Elective NCS

Symptoms or LV dysfunction

Consider TAVI or balloon aortic

valvuloplasty

before NCS if doable, or NCS

under strict

monitoring NCS NCS under strict monitoring Heart Team

decision: SAVR or TAVI

Risk of NCS Risk of NCS

Patient risk for

AV procedure

(TAVI/SAVR)

Figure 21 Management of non-cardiac surgery in patients with severe aortic stenosis. AS, aortic stenosis; AV, aortic valve; LV, left ventricular; NCS, non-cardiac surgery; SAVR, surgical aortic valve replacement; TAVI, transcatheter aortic valve implantation.

ESC Guidelines                                                                                                                                                                                          4701

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