2025 ESC/EACTS Valvular Heart Disease Guidelines Summary

ESC/EACTS 2025 GUIDELINES

Valvular Heart

Disease

Management Guidelines — Key Recommendations & Updates

Published August 2025

Heart Team Approach

Updated Evidence-Based

European Society of Cardiology (ESC) & European Association for Cardio-Thoracic Surgery (EACTS)

Presentation Outline

01

Introduction & Overview

02

Heart Team & Heart Valve Centres

03

Diagnostic Advances & Imaging

04

Aortic Stenosis (AS)

05

Aortic Regurgitation (AR)

06

Mitral Regurgitation (MR)

07

Tricuspid Valve Disease

08

Prosthetic Valves & Antithrombotic Management

Introduction & Scope of the 2025 Guidelines

<b style="color: #FFFFFF;">Published:</b> August 29, 2025 — Update to the 2021 ESC/EACTS VHD Guidelines

<b style="color: #FFFFFF;">Covers:</b> Acquired valvular heart disease in adults

Integrates new RCT evidence on TAVI, TEER, and transcatheter tricuspid interventions

Emphasis on patient-centered, lifetime management strategies

Endorsed by multiple national cardiac societies worldwide

The right intervention, for the right patient, at the right time — by the right team.

8

Major Valvular Conditions Covered

100+

New Evidence-Based Recommendations

2021 → 2025

Major Updates Incorporated

Heart Team & Heart Valve Centres

Class I Recommendation

Core Heart Team Members

🫀

Imaging Cardiologist

⚕️

Interventional Cardiologist

🔪

Cardiac Surgeon

Extended Team Members

Heart Failure Specialist

Geriatrician

Anesthesiologist

Neurologist / Stroke Team

Heart Valve Centres must perform ≥100 valve procedures/year

(≥50 TAVI · ≥25 SAVR)

📊

High Volume = Better Outcomes

Volume-outcome data supports referral for complex procedures

🌐

Multidisciplinary Networks

Triage patients from surveillance clinics to intervention centres

🛡️

Reduces Undertreatment

Systematic approach improves diagnosis and treatment rates

Diagnostic Advances & Multimodality Imaging

Multimodality imaging is central to precise VHD assessment, staging, and procedural planning.

ECHOCARDIOGRAPHY

3D Echo for precise anatomy

Vena contracta area for MR/TR

Exercise stress echo for dynamic assessment

Pitfalls in mixed/multivalvular disease

ADVANCED IMAGING

Cardiac CT (CCTA): Class I for low-moderate CAD risk pre-intervention

CMR for myocardial fibrosis & function

3D printing for procedural planning

CT for TAVI sizing & access planning

BIOMARKERS & TESTS

NT-proBNP for risk stratification

Exercise testing for asymptomatic patients

6-minute walk test

Frailty assessment tools

CCTA now Class I recommendation before valve interventions in patients with moderate or lower pretest likelihood of CAD (Level of Evidence B)

Aortic Stenosis

Key 2025 Recommendations

Age Cutoff Lowered

TAVI preferred ≥70 yrs (was ≥75 yrs)

Early Intervention

Asymptomatic severe AS: Class IIa for low-risk (LVEF >50%)

TAVI PREFERRED

Age ≥70 years

High/intermediate surgical risk

Tricuspid aortic valve

Limited life expectancy

Frailty / comorbidities

SAVR PREFERRED

Age <70 years

Young, low-risk patients

Bicuspid aortic valve / root disease

Long life expectancy / durability needed

Good surgical candidate

Class I

Symptomatic severe AS → Intervention indicated

Class IIa

Asymptomatic severe high-gradient AS, low-risk, LVEF >50%

Class IIb

TAVI for bicuspid AS or high-risk aortic regurgitation

Aortic Regurgitation — Management Updates

SURGICAL INDICATIONS (Class I)

Symptomatic severe AR

Asymptomatic severe AR with LVEF ≤50%

Asymptomatic severe AR with LVESD >50mm or LVEDD >70mm

Severe AR undergoing other cardiac surgery

NEW 2025 UPDATE

Class IIb: TAVI may be considered for severe AR in patients ineligible for surgery (Level B)

MEDICAL MANAGEMENT

Vasodilators (ACE inhibitors/ARBs) for symptomatic patients

Beta-blockers for Marfan/aortopathy patients

Regular surveillance imaging (echo every 1–2 years for moderate AR)

Mild

Moderate

Severe

LVEF ≤50% or LVESD >50mm

Aortic root/ascending aorta intervention thresholds remain at ≥55mm (≥50mm for Marfan/bicuspid)

Mitral Regurgitation — Primary & Secondary MR

Primary (Degenerative) MR

Class I Surgery Indications:

Symptomatic severe primary MR

Asymptomatic severe MR with LVEF 60–70% or LVESD 40–45mm

Asymptomatic severe MR + new AF or pulmonary hypertension

Repair preferred over replacement. Minimally invasive approaches endorsed.

Repair rate >90% at experienced centres

Secondary (Functional) MR

Ventricular SMR:

Class I: TEER (MitraClip/PASCAL) if COAPT criteria met (ERO ≥0.3 cm²) after optimized GDMT

Reduces HF hospitalizations significantly

Atrial SMR:

Class IIa: Surgery or TEER if symptomatic despite GDMT

Address underlying AF and left atrial dilation

TEER upgraded to Class I for ventricular secondary MR meeting COAPT criteria — after guideline-directed medical therapy optimization

Tricuspid Valve Disease — Updated Recommendations

2025 Upgrades at a Glance

Concomitant TR Repair: Class I

Isolated TR Surgery: Class IIa

Transcatheter TEER for TR: Class IIa

Indications for TR Intervention

Class I

Concomitant tricuspid repair during left-sided valve surgery (even for moderate TR if progressive)

Severe symptomatic TR after left-sided surgery

Class IIa

Isolated severe symptomatic TR despite GDMT → Surgery or transcatheter TEER/replacement

TR with right heart dilation before irreversible RV dysfunction

Transcatheter Tricuspid Options

TEER (edge-to-edge repair) — e.g., TriClip, PASCAL

Transcatheter tricuspid replacement (TTVR)

Bicaval valve implantation for severe TR

Transcatheter options expanding rapidly — RCT evidence growing

Early intervention before irreversible RV dysfunction is critical for improved outcomes

Mitral Stenosis — Rheumatic & Calcific

Rheumatic Mitral Stenosis

MVA ≤ 1.5 cm² = Severe MS

Symptomatic severe MS (MVA ≤ 1.5 cm²)

Asymptomatic severe MS with new-onset AF or pulmonary HTN

Percutaneous Mitral Commissurotomy (PMC) if favorable anatomy (Wilkins score ≤ 8), no MR, no thrombus

Mitral valve replacement if PMC not suitable

Calcific Mitral Annular Disease

Emerging transcatheter options for MAC-related MS

Higher procedural risk due to calcification

Transcatheter mitral valve replacement (TMVR)

— Class IIb consideration

Careful patient selection with CT planning essential

All patients with MS and AF: Anticoagulation with VKA (not DOACs) — Class I

Asymptomatic MS with AF: Anticoagulation indicated regardless of stroke risk score

Prosthetic Valves & Antithrombotic Therapy

Patient education on anticoagulation self-monitoring is strongly emphasized in 2025 guidelines.

What's New?

2021 → 2025 Key Updates

TAVI Age Threshold

UPDATED

Age cutoff for TAVI preference lowered from <span style="color:#FFFFFF; font-weight:600;">75 → 70 years</span> for tricuspid aortic stenosis

Asymptomatic AS

UPDATED

<span style="color:#FFFFFF; font-weight:600;">Class IIa:</span> Early intervention for asymptomatic severe high-gradient AS in low-risk patients (LVEF &gt;50%) — supported by EARLY TAVR trial

Secondary MR TEER

UPGRADED

TEER upgraded to <span style="color:#FFFFFF; font-weight:600;">Class I</span> for ventricular SMR meeting COAPT criteria after optimized GDMT

Tricuspid Intervention

UPGRADED

Concomitant TR repair: <span style="color:#FFFFFF; font-weight:600;">Class I</span>. Isolated severe TR: <span style="color:#FFFFFF; font-weight:600;">Class IIa</span> for surgery or transcatheter TEER

CCTA Pre-Intervention

NEW

CCTA now <span style="color:#FFFFFF; font-weight:600;">Class I</span> before valve interventions in patients with moderate or lower CAD risk (Level B)

AR Transcatheter

NEW

<span style="color:#FFFFFF; font-weight:600;">Class IIb:</span> TAVI may be considered for inoperable severe aortic regurgitation (Level B)

These updates reflect integration of landmark RCT evidence (EARLY TAVR, COAPT, TRILUMINATE)

Summary & Key Takeaways

2025 Guidelines | European Society of Cardiology

Heart Team approach is mandatory

— multidisciplinary, high-volume centres deliver best outcomes

Earlier intervention thresholds

— asymptomatic patients now benefit from timely treatment

TAVI is preferred ≥70 years for AS;

transcatheter options expanding across all valves

Multimodality imaging (echo, CCTA, CMR)

is essential for diagnosis and procedural planning

Lifetime management perspective

— consider durability, reintervention risk, and patient values

The goal is to deliver the right intervention, to the right patient, at the right time — by the right multidisciplinary team.