Perioperative management of adults with heart valve disease having noncardiac surgery: a narrative review

PURPOSE OF REVIEW: This article reviews the perioperative management of adults with heart valve disease undergoing noncardiac surgery. It focuses on aortic and mitral valve disease, as well as prosthetic heart valves, in the context of the substantial hemodynamic challenges imposed by anesthesia during major surgery. We aim to integrate guideline-based recommendations for preoperative evaluation and risk stratification with pathophysiological principles to support individualized intraoperative hemodynamic and anesthetic management. RECENT FINDINGS: Current literature and guidelines converge on symptom status and echocardiographic severity as key determinants of perioperative risk. For stenotic lesions, maintaining sinus rhythm, avoiding tachycardia, preserving preload, and preventing abrupt afterload reduction are central intraoperative goals. For regurgitant lesions, strategies that support forward flow by avoiding bradycardia and excessive afterload are emphasized. In prosthetic valves, perioperative management is driven by valve type/position and thromboembolic risk, guiding anticoagulation interruption and bridging, while endocarditis prophylaxis is reserved for selected high-risk dental procedures. SUMMARY: A practical approach integrates surgical urgency, valve severity, symptoms, ventricular function, and pulmonary pressures to determine whether to proceed with surgery, optimize medically, or to perform valve intervention first, and to tailor intraoperative monitoring and anticoagulation plans.