2025 ESC/EACTS Guidelines for the management of valvular heart disease: Developed by the task force for the management of valvular heart disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)
Introduction
New evidence has accumulated since the publication of the 2021 European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) Guidelines for the management of valvular heart disease, leading to the need for new recommendations (Table 3 New recommendations) and revision of existing recommendations (Table 4 Revised recommendations) concerning the following topics:
- The importance of shared and patient-centred decision-making by multidisciplinary expert Heart Teams working within a regional network has been reinforced. Patients with complex conditions or requiring complex procedures should be referred to high-volume centres, where corresponding expertise is concentrated to ensure high-quality treatment.
- Advanced imaging modalities—such as three-dimensional (3D) echocardiography, cardiac computed tomography (CCT), and cardiac magnetic resonance (CMR) imaging—have gained importance and become a central aspect in the screening and evaluation of patients with valvular heart disease (VHD).
- Emphasis is put on the importance of correctly assessing the cause(s) and mechanism(s) of all valve diseases. In particular, the distinction between atrial and ventricular secondary mitral regurgitation (SMR) has clear implications in terms of prognosis and management.
- New evidence has been published regarding the benefits of intervention for the treatment of severe aortic stenosis (AS) irrespective of symptoms, left ventricular ejection fraction (LVEF), and flow reserve.
- The criteria used for decision-making concerning the optimal modality of AS treatment [transcatheter aortic valve (AV) implantation (TAVI) or surgical AV replacement (SAVR)] based on a Heart Team approach have been refined, including the combination of key aspects such as age, procedural risk, and anatomical suitability, incorporating estimated life expectancy and lifetime management considerations.
- Further randomized evidence confirming the mid-term safety and efficacy of TAVI in low-risk patients has been published.
- The indications for TAVI in patients with bicuspid AV (BAV) stenosis or severe aortic regurgitation (AR) at high surgical risk, based on anatomical suitability and a comprehensive Heart Team evaluation, are discussed.
- Several advancements have been made regarding the treatment of patients with primary mitral regurgitation (PMR): refinement of the criteria for intervention in asymptomatic patients; demonstration of the value of minimally invasive mitral valve (MV) surgery to reduce the length of hospital stay and accelerate recovery; and large-scale data confirming the role of transcatheter edge-to-edge repair (TEER) in high-risk patients.
- Longer-term follow-up data and two new randomized controlled trials (RCTs) concerning the management of patients with ventricular SMR have been published.
- The evidence for the treatment of tricuspid valve (TV) disease is growing—including new randomized data supporting concomitant TV repair during left-sided valve surgery, and transcatheter options (repair and replacement) that reduce tricuspid regurgitation (TR), promote reverse right ventricular (RV) remodelling, and improve quality of life compared with medical treatment.
- Efforts have been made to provide improved guidance regarding the diagnostic steps and management of patients with multiple and mixed VHD.
- Definitions of structural valve deterioration (SVD) have been updated and unified.
- The recommendations concerning the use of direct oral anticoagulants (DOACs) in patients with VHD have been updated, and the importance of education and (self-)monitoring is emphasized.
- Sex-specific considerations in patients with VHD have been extended and regrouped into a new dedicated section (see Section 17).
Because of demographic changes, patients with VHD frequently present with concomitant cardiovascular diseases, increasing the complexity of treatment strategies. These Guidelines focus on acquired VHD and do not deal in detail with overlapping cardiovascular diseases such as infective endocarditis,5 chronic coronary syndrome,6 and atrial fibrillation (AF),7 as well as all scenarios of aortic or congenital disease,8,9 because these topics are covered in separate Guidelines.
The 2025 ESC/EACTS Guidelines for the management of valvular heart disease aim to be concise, focused on relevant issues for clinicians and patients, and to provide clear and simple practical recommendations, assisting healthcare providers in their daily clinical decision-making. A compilation of the evidence considered for new recommendations, or those with an updated class of recommendation or level of evidence, can be consulted online (see Supplementary data online, Evidence Tables). The Task Force for these Guidelines acknowledges that multiple factors influence and ultimately determine the most appro- priate treatment of individual patients within a given community. These factors include the availability of equipment and technology, and the expertise and volumes, in complex procedures, such as valve repair or transcatheter interventions. Moreover, given the lack of evi- dence on some topics related to VHD, several recommendations are the result of expert consensus opinion. Therefore, deviations from these Guidelines may be appropriate in certain clinical circumstances, and decision-making should always be based on a collaborative, multi- disciplinary Heart Team approach centred on individual characteris- tics, needs, and prognosis, as well as the preferences of the informed patient.