2025 ESC/EACTS Guidelines for the management of valvular heart disease: New Recommendations

Written by Dr. Kübra Okumuş

Reference: Praz F, et al. 2025 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J. 2025. doi: 10.1093/eurheartj/ehaf194.

The 2025 ESC/EACTS Guidelines on Valvular Heart Disease offer significant updates in diagnostic and interventional areas. Key highlights include the adjustment of the age threshold for TAVI, the growing emphasis on multimodality imaging, the expanding role of CT in coronary assessment, new classifications for mitral valve disease, and strengthening the Heart Team approach. These recommendations not only improve treatment algorithms but also emphasize patient-centered decision-making and long-term care strategies.

1. Diagnostic Approach and Management of Coronary Artery Disease
The new guideline redefines the assessment of coronary artery disease in patients with valvular heart disease. Invasive coronary angiography is now recommended for patients with high or very high pre-test probability, whereas coronary computed tomography angiography (CCTA) has become the preferred modality in those with low-to-intermediate probability. This shift supports a less invasive and more accessible diagnostic approach, particularly in patients being evaluated for surgical or transcatheter valve intervention.

Coronary Artery Disease;

• Omission of invasive coronary angiography should be considered in TAVI candidates, if procedural planning CT angiography is of sufficient quality to rule out significant CAD. (IIa)
• PCI should be considered in patients with a primary indication to undergo TAVI and ≥90% coronary artery stenosis in segments with a reference diameter ≥2.5 mm. (IIa)

** Imaging-based selection reduces the burden of invasive procedures and accelerates TAVI planning. However, invasive confirmation remains necessary in patients with complex or high-risk lesions.
2. Aortic Valve Disease; Updated Recommendations
Severe Aortic Regurgitation (AR):

• TAVI may be considered for the treatment of severe AR in symptomatic patients ineligible for surgery according to the Heart Team, if the anatomy is suitable. (IIb)

** While previous guidelines indicated surgery as the first-line treatment for severe AR, TAVI emerges as an important new recommendation for symptomatic patients who are not candidates for surgery in the 2025 guidelines.

Severe Aortic Stenosis (AS):

• The age limit for TAVI has been lowered to 70 years, one of the most notable updates in the new guidelines. The lowering of the age of indication for TAVI in tricuspid AS from 75 to 70 years demonstrates that TAVI is no longer limited to elderly, high-risk patients but can now be performed in younger individuals with favorable anatomy.
• Intervention should be considered in asymptomatic patients (confirmed by a normal exercise test, if feasible) with severe, high-gradient AS and LVEF ≥50%, as an alternative to close active surveillance, if the procedural risk is low. (IIa)
• TAVI may be considered for the treatment of severe BAV stenosis in patients at increased surgical risk, if the anatomy is suitable.  (IIb)

** The timing of intervention should be individualized by the Heart Team, particularly in young, low-risk, asymptomatic patients. TAVI is now expanding beyond high-risk elderly populations to a broader range of patients with appropriate anatomy and risk profiles.

3. Mitral Valve Disease; New Approaches
The 2025 guideline clarifies the differentiation between primary (organic) and secondary (functional) mitral regurgitation (MR), introducing a clearer subclassification of secondary MR into atrial and ventricular types.

Primary Mitral Regurgitation (PMR):
Surgical repair remains the gold standard for primary MR.

• Surgical MV repair is recommended in low-risk asymptomatic patients with severe PMR without LV dysfunction (LVESD <40 mm, LVESDi <20 mm/m2, and LVEF >60%) when a durable result is likely, if at least three of the following criteria are fulfilled: (I)
• AF
• SPAP at rest >50 mmHg
• LA dilatation (LAVI ≥60 mL/m2 or LA diameter ≥55 mm)
• Concomitant secondary TR ≥ moderate

• Minimally invasive MV surgery may be considered at experienced centres to reduce the length of stay and accelerate recovery. (IIb)

Secondary Mitral Regurgitation (SMR):
For atrial SMR, the 2025 guideline recommends surgical repair as Class IIa, and the transcatheter approach as Class IIb.

• MV surgery, surgical AF ablation, if indicated, and LAAO should be considered in symptomatic patients with severe atrial SMR under optimal medical therapy. (IIa)
• TEER may be considered in symptomatic patients with severe atrial SMR not eligible for surgery after optimization of medical therapy including rhythm control, when appropriate. (IIb)
• MV surgery may be considered in patients with moderate SMR undergoing CABG. (IIb)

Rheumatic and Degenerative Mitral Stenosis (MS):

• Transcatheter mitral valve implantation may be considered in symptomatic patients with extensive MAC and severe MV dysfunction at experienced Heart Valve Centres with expertise in complex MV surgery and transcatheter interventions. (IIb)

** Notably, the 2025 guideline upgrades early surgical repair in asymptomatic PMR with low surgical risk from a Class IIa to a Class I recommendation. Even in asymptomatic cases, the presence of secondary TR, pulmonary hypertension, AF, or LA dilatation supports consideration of early surgical repair and emphasizes a preventive and disease-modifying approach. Additionally, for the first time, TMVI is formally included as a therapeutic option for senile degenerative MS, bringing transcatheter interventions into consideration for this patient group.

4. Tricuspid and Concomitant Valve Disease
Tricuspid Regurgitation (TR):

• Careful evaluation of TR aetiology, stage of the disease (i.e. degree of TR severity, RV and LV dysfunction, and PH), patient operative risk, and likelihood of recovery by a multidisciplinary Heart Team is recommended in patients with severe TR prior to intervention. (I)

Combined Valve Disease:

• MV surgery is recommended in patients with severe MR undergoing surgery for another valve. (I)
• Intervention is recommended in symptomatic patients with mixed moderate AV stenosis and moderate regurgitation, and a mean gradient ≥40 mmHg or Vmax ≥4.0 m/s. (I)
• Intervention is recommended in asymptomatic patients with mixed moderate AV stenosis and moderate regurgitation, with Vmax ≥4.0 m/s and LVEF <50% not attributable to other cardiac disease. (I)

** Timely intervention in TR is crucial to preserve right ventricular function and improve long-term outcomes. The 2025 guideline elevates multidisciplinary evaluation in isolated TR to a Class I recommendation, emphasizing early, patient-centered decision-making and a proactive management approach.

5. Prosthetic Valve Selection and Antithrombotic Therapy Management
Prosthesis Selection:

• An mechanic heart valve (MHV) should be considered in patients with an estimated long life expectancy, if there are no contraindicatons for long-term oral anticoagulation (OAC). (IIa)

Antithrombotic Therapy Management:

• It is recommended that INR targets are based on the type and position of MHV, patient’s risk factors, and comorbidities. (I)
• Patient education is recommended to improve the quality of OAC. (I)
• Continuing VKA treatment is recommended in patients with an MHV for minor or minimally invasive interventions associated with no or minimal bleeding. (I)
• Interruption (3–4 days before surgery), and resumption of VKA without bridging, may be considered to reduce bleeding in patients with new-generation aortic MHV and no other thromboembolic risk factors undergoing major non-cardiac surgery or invasive procedures. (IIb)
• Lifelong low-dose ASA (75–100 mg/day) may be considered 3 months after surgical implantation of an aortic or mitral BHV in patients without clear indication for OAC. (IIb)
• Low-dose ASA (75–100 mg/day) may be considered after surgical MV or TV repair in preference to OAC in patients without clear indication for OAC and at high bleeding risk. (IIb)
• DAPT is not recommended to prevent thrombosis after TAVI, unless there is a clear indication. (III)
• OAC continuation is recommended in patients with a clear indication for OAC undergoing surgical bioprosthetic heart valve (BHV) implantation. (I)
• DOAC continuation may be considered after surgical BHV implantation in patients with an indication for DOAC. (IIb)
• Continuation of OAC or antiplatelet therapy should be considered after surgical valve repair in patients with a clear indication for an antithrombotic therapy. (IIa)

Valve Dysfunction and Thrombosis:

• Reoperation is recommended in symptomatic patients with significant valve dysfunction not attributable to valve thrombosis. (I)
• TOE and/or 4D-CT are recommended in patients with suspected valve thrombosis to confirm the diagnosis. (I)

** In patients with MHV, INR targets are now recommended in a more dynamic manner, taking into account valve type, position, and patient-specific risk profiles. Patient education to improve the effectiveness of OAC is emphasized as a Class I recommendation in the 2025 guideline. This approach highlights not only technical procedural success but also the sustainability of therapy and active patient participation in management. Regarding antithrombotic therapy, continuation of VKA is recommended for minor or minimally invasive procedures with low bleeding risk. In patients with new-generation aortic MHVs and no additional thromboembolic risk factors, VKA may be interrupted 3–4 days before major surgery or invasive procedures and restarted without bridging, aiming to reduce unnecessary interruptions and minimize bleeding risks associated with bridging. After surgical BHV implantation, patients without a clear indication for OAC may receive lifelong low-dose aspirin (75–100 mg/day) from three months postoperatively, whereas those with an OAC indication should continue OAC. Additionally, DOAC use is considered a Class IIb option in this population. Following valve repair, low-dose aspirin may be appropriate for patients without OAC indication but at high bleeding risk, emphasizing individualized therapy. After TAVI, single antiplatelet therapy is recommended to avoid unnecessary dual therapy.

Commentary: Toward Earlier, More Patient-Centered Care
The 2025 guideline redefines not only clinical algorithms but also the organizational model of care. The recommendation for multidisciplinary Heart Team decision-making in all complex cases has been reinforced. Additionally, Heart Valve Centers with high procedural volume and extensive experience are encouraged, as they can reduce complication rates and enhance operator expertise. The ESC/EACTS 2025 guideline represents a paradigm shift in valvular heart disease management, emphasizing early diagnosis, patient-centered decision-making, team-based care, advanced imaging, and optimal timing of interventions. The 2025 recommendations aim not only to improve procedural success but also to enhance patient-centered decision-making, long-term prognosis, and overall quality of care.