2025 ESC/EACTS Guidelines for the management of valvular heart disease
30 Aug 2025
2025 ESC/EACTS Guidelines for the management of valvular heart disease The first of this year’s new guidelines was unveiled yesterday by Professor Fabien Praz (Bern University Hospital, University of Bern - Bern, Switzerland) and Professor Michael A. Borger (Leipzig Heart Center - Leipzig, Germany), Chairs of the Joint ESC and EACTS Guidelines Task Force.1
“Valvular heart disease (VHD), in all its many forms, continues to be underdiagnosed and undertreated,” highlights Prof. Praz. “We begin the new guidelines by reinforcing the importance of multidisciplinary expert Heart Teams working within regional networks to ensure timely, accurate diagnosis and appropriate treatment selection. If a complex procedure is needed, we believe this should be conducted at an experienced high-volume centre to maintain quality. The new guidelines provide a list of such interventions.”
Prof. Borger comments: “Another area of focus in the new guidelines is the central role of advanced imaging modalities for accurately assessing the exact cause(s) and mechanism(s) of VHD, because of the implications for prognosis and management. For example, the document has adopted, for the first time, new categories to more precisely define different subtypes of secondary mitral regurgitation.”
Regarding aortic stenosis, the criteria used to decide the optimal treatment modality (transcatheter aortic valve implantation [TAVI] or surgical replacement) have been refined in the light of the new evidence published since 2021 and involve Heart Team assessment of a combination of key aspects, including clinical characteristics (age and estimated life expectancy, concomitant conditions and patient’s preference), access and valve anatomy, as well as the patient’s lifetime trajectory, in anticipation of future procedures. In the newly released guidelines, TAVI has been extended to anatomically suitable patients aged 70 years or older, irrespective of the estimated surgical risk, if the aortic valve is tricuspid. “Surgery continues to play a key role in younger low-risk patients in whom several interventions may be needed and in those with a bicuspid anatomy,” stresses Prof. Borger. For all patients with asymptomatic severe high gradient aortic stenosis, a new Class IIa recommendation encouraging early treatment has been created.
The new guidelines also consider advancements made in the treatment of severe primary mitral regurgitation, including a new Class IA recommendation for early surgical repair of asymptomatic patients. The recommendation regarding transcatheter edge-to-edge repair (TEER) in high-risk patients has been also upgraded (Class IIa, Level B).
In patients with heart failure and symptomatic severe ventricular secondary mitral regurgitation (LVEF <50%) fulfilling specific criteria, TEER now has a Class I recommendation to reduce heart failure hospitalisations and improve quality of life. “This is a major advancement for the patients in whom optimised guideline-directed medical therapy and resynchronisation (if indicated) fail to reduce symptoms,” mentions Prof. Praz.
The indication for concomitant tricuspid valve repair in patients undergoing left-sided surgery associated with moderate or severe tricuspid regurgitation has been reinforced, while transcatheter treatment of the tricuspid valve is considered to improve quality of life and RV remodelling in high-risk patients with symptomatic severe tricuspid regurgitation.
The section on the use of antithrombotic therapy in patients with VHD, as well as recommendations for the management of valve dysfunction, have been adapted with several new and revised recommendations to robustly support daily practice.
Brand-new or extended sections include the management of patients with cancer and VHD, those presenting with acute heart failure, and those with multiple or mixed VHD. A dedicated section also discusses the importance of a sex-specific approach in the management of VHD.
Want to know more about what’s new? The 2025 ESC Guidelines are now published in the European Heart Journal and are available on the ESC Pocket Guidelines app.
References
- Praz F, Borger M, et al. 2025 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2025. doi:10.1093/eurheartj/ehaf194.
