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Perioperative Cardiovascular Evaluation

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5 Table 3. Valvular Heart Disease, CIEDs and Pulmonary Vascular Disease (cont'd) Recommendations COR LOE Aortic and Mitral Regurgitation Elevated-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable in adults with asymptomatic severe MR. IIa C Elevated-risk elective noncardiac surgery with appropriate intraoperative and postoperative hemodynamic monitoring is reasonable in adults with asymptomatic severe AR and a normal LVEF. IIa C CIEDs Before elective surgery in a patient with a CIED, the surgical/procedure team and clinician following the CIED should communicate in advance to plan perioperative management of the CIED. I C Patients with ICDs who have preoperative reprogramming to inactivate tachytherapy should be on a cardiac monitor continuously during the entire period of inactivation, and external defibrillation equipment should be available. Systems should be in place to ensure that ICDs are reprogrammed to active therapy before discontinuation of cardiac monitoring and discharge from the facility. I C Pulmonary Vascular Disease Chronic pulmonary vascular targeted therapy (i.e., phosphodiesterase type 5 inhibitors, soluble guanylate cyclase stimulators, endothelin receptor antagonists, and prostanoids) should be continued unless contraindicated or not tolerated in patients with pulmonary hypertension who are undergoing noncardiac surgery. I C Unless the risks of delay outweigh the potential benefits, preoperative evaluation by a pulmonary hypertension specialist before noncardiac surgery can be beneficial for patients with pulmonary hypertension, particularly for those with features of increased perioperative risk. a IIa C a Features of increased perioperative risk in patients with pulmonary hypertension include: 1) diagnosis of Group 1 pulmonary hypertension (i.e., pulmonary arterial hypertension), 2) other forms of pulmonary hypertension associated with high pulmonary pressures (pulmonary artery systolic pressures >70 mm Hg ) and/or moderate or greater right ventricular dilatation and/or dysfunction and/or pulmonary vascular resistance >3 Wood units, and 3) World Health Organization/New York Heart Association class III or IV symptoms attributable to pulmonary hypertension.

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