Essential Messages and Limitations from the 2025 ESC Guidelines for Valvular Heart Disease

Written by Dr. Emre Aydın

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.

Essential messages
Heart Team and Heart Valve Centre

• A regional Heart Valve Network integrating outpatient clinics and specialist centres ensures optimal patient care.
• Centres should meet institutional standards, maintain high procedural volumes, and achieve excellent outcomes.
• Heart Team decisions should follow guideline recommendations, current evidence, and patient preferences.
• Core members include the clinical cardiologist, VHD specialists, imaging experts, and experienced surgeons/interventionalists.
• Complex procedures should be concentrated in high-volume centres, with network details shared transparently with patients and referring physicians.

Aortic Regurgitation (AR)

• Assessing AR severity by TTE remains challenging; current intervention cut-offs rely mainly on 2D data, while 3D echo and CMR provide more accurate LV assessment.
• AR mechanisms are linked to aortic diameters, which should be measured precisely at all root levels.
• Surgery is indicated based on symptoms, LV size and function, and aortic dimensions. Valve replacement is standard, but repair or valve-sparing surgery is increasingly performed in experienced centres.
• Transcatheter options remain limited to patients unsuitable for surgery.

Aortic Stenosis (AS)

• Diagnosis of severe AS requires an integrated assessment of pressure gradients, AVA, flow, valve calcification, and LV function.
• The choice of intervention should consider clinical factors (age, comorbidities, life expectancy), valve and access anatomy, surgical risk, and lifetime management options.

Mitral regurgitation (MR)

• Echocardiographic evaluation of MR includes multiparametric severity assessment, 3D TOE anatomical evaluation, mechanism identification (PMR, ventricular or atrial SMR), and assessment of cardiac damage.
• Surgical repair is preferred for severe PMR; transcatheter edge-to-edge repair is an option for inoperable or high-risk patients.
• In asymptomatic PMR with signs of cardiac damage (including ≥moderate TR), surgical repair is recommended.
• In ventricular SMR, GDMT (±CRT) is first-line; M-TEER is advised for symptomatic patients without revascularization needs, while surgery may be considered in complex CAD or TEER-ineligible cases.
• In atrial SMR, after optimal medical therapy, MV surgery with AF ablation and/or LAAO may be considered; TEER is an option for high-risk patients.

Mitral stenosis (MS)

• PMC is the standard treatment for severe rheumatic MS with suitable valve anatomy. Surgery is recommended for symptomatic patients with contraindications or unfavourable anatomy for PMC.
• In patients with unfavourable anatomy, decisions should consider local PMC expertise.
• In selected patients with severe degenerative MS and MAC, transcatheter or surgical intervention may relieve symptoms.

Tricuspid regurgitation (TR)

• Concomitant TV repair is the preferred method for patients with left-sided valve pathology and associated moderate or severe TR.
• The use of risk scores for the assessment of RV and secondary organ dysfunction should be strongly encouraged in patients with isolated severe TV disease.
• In isolated severe TR without severe RV dysfunction, surgery should be performed at an early stage in patients at low operative risk.
• In isolated severe TR patients at increased surgical risk, tricuspid TEER or transcatheter replacement should be considered to improve quality of life and RV remodelling, in the absence of severe RV dysfunction or pre-capillary PH.

Tricuspid stenosis (TS)

• TS is a very rare manifestation of acquired VHD in high-income countries.
• TS is mainly associated with rheumatic valve disease, carcinoid syndrome, or enzymatic disorders such as Fabry’s or Whipple’s disease.
• Treatment of symptomatic TS mainly involves surgical TV replacement.

Multiple and mixed valvular heart disease

• Transvalvular gradients and velocities reflect the combined burden of regurgitation and stenosis in mixed aortic and mitral disease.
• Treatment decisions should be based on the assessment of symptom and functional status, cardiac damage, anatomical suitability, and the risk–benefit ratio of intervention and lifetime management considerations.
• Patients with mixed moderate AS and AR have similar detrimental outcomes compared with those with severe isolated AS.
• In transcatheter procedures, which allow a sequential approach, downstream lesions should be treated first to prevent potential haemodynamic deterioration and allow improvement of upstream lesions due to changing loading conditions and reverse remodelling.

Antithrombotic treatment in patients with a mechanical heart valve

• International normalized ratio (INR) therapeutic range should be balanced to the type and anatomical site of MHV, as well to the thrombotic risk profile of the individual patient.
• Patient training, self-monitoring, and education can increase INR stability and TTR.
• Minor or minimally invasive NCS procedures do not require VKA interruption in patients with an MHV.
• In patients with an MHV undergoing elective major NCS, bridging may be omitted if the thromboembolic risk is low.

Non-cardiac surgery (NCS)

• The risk of peri-operative cardiovascular complications related to surgery and to patient-specific factors should be evaluated and communicated to the patient and surgical team.
• In patients with symptomatic severe AS requiring urgent high-risk NCS, BAV or TAVI should be considered prior to surgery. In patients planned for elective NCS, AV intervention is recommended prior to NCS.

Pregnancy

• In women with VHD, decisions regarding management before and during pregnancy should be taken after discussion by the multidisciplinary Pregnancy Heart Team. Unplanned pregnancies should be discouraged.
• The following conditions should be corrected prior to considering pregnancy:
• Clinically severe MS (MVA <1.5 cm2), even when asymptomatic
• severe symptomatic AS, or asymptomatic patients with impaired LV function or a pathological exercise test
• heritable aortic disorders and high risk of aortic dissection.
• Vaginal delivery is the first choice for the majority of patients. Indications for Caesarean section include pre-term labour in patients on OAC, severe MS or AS, aggressive aortic pathology, acute intractable HF, and severe PH.
• Women with MHVs should be managed in expert centres.

Limitations
Heart Team and Heart Valve Centre

• Structured research is required to investigate the relationship between procedural volume and clinical outcomes, in order to define minimum annual thresholds for individual operators and institutions undertaking surgical and transcatheter valve interventions.
• There is a pressing need to ensure higher dispersion and adoption of interventions for VHD, especially in middle- and low-income countries.

Conditions associated with valvular heart disease
CAD:

• The prognostic value of functional assessment of stable, moderate coronary stenosis in VHD patients remains to be determined.
• The optimal strategy (invasive vs non-invasive) for CAD assessment in specific VHD populations remains to be elucidated.
• The optimal timing of PCI in patients with CAD undergoing TAVI is yet to be determined.
• The benefit of complete coronary revascularization with CABG in patients with combined VHD and CAD requires further research.

Atrial fibrillation:

• It is unclear which patients with chronic persistent AF and concomitant VHD are deemed to be suitable for rhythm control therapy.
• The protective effect against stroke of OAC with VKA or DOACs in patients after surgical or transcatheter LAAO remains to be determined.

Cardiogenic shock and acute HF:

• The optimal treatment strategy in VHD patients presenting with cardiogenic shock and acute HF is unknown.

Aortic regurgitation:

• Impact of early LV remodelling on prognosis in asymptomatic AR patients is unknown.
• Prognostic value of CMR-derived indices in asymptomatic patients needs to be determined.
• More data are required on long-term results of surgical AV repair for AR.
• More evidence is required on transcatheter treatment options for AR, in particular using dedicated devices.

Aortic stenosis:

• Better understanding of the pathophysiology of AS is needed to propose innovative medical therapy.
• Further research is required on: Refined prognostic markers to guide timing of intervention in asymptomatic patients.
• The role of revascularization in patients with severe AS and asymptomatic concomitant CAD.
• Further data on the long-term durability of transcatheter valves in comparison with surgical BHVs in younger patients.
• The role of TAVI in patients with BAV AS and patients <70 years of age.
• Results of intervention (valve or coronary) after TAVI or SAVR.
• Determining the optimal lifetime management strategy for AS patients.

Mitral regurgitation:

• The association between primary MR and ventricular arrhythmias requires more investigation, including the impact of intervention on ventricular arrhythmias.
• More data are required on the role of TEER in patients with advanced HF.
• Long-term results of TEER need to be further assessed, including the clinical relevance of transmitral gradients after treatment of both primary and secondary MR.
• Results of ongoing trials comparing MV surgery with TEER in non-high risk primary MR patients are awaited.
• Data on the mid- and long-term clinical impacts of transcatheter MV replacement are required.
• More data on the clinical impacts of surgical and transcatheter treatment of atrial SMR are required.

Mitral stenosis:

• The potential role of TMVI using dedicated devices in high-risk patients is to be determined, particularly those with severe MAC.

Tricuspid regurgitation:

• The long-term risks and benefits of concomitant TV surgery in patients with less than moderate TR and annular dilatation undergoing left-sided valve surgery need to be determined.
• Further investigations are required on the outcomes of TV intervention in asymptomatic patients with severe TR and RV dysfunction or significant dilation.
• The importance of addressing concomitant AF in patients with TR needs to be investigated.
• More data are required on the indications, timing, and long-term outcomes of TV repair and replacement for TV disease.
• Better understanding is required of the respective role of surgery vs transcatheter TV therapy for TR treatment.

Tricuspid stenosis:

• The role of transcatheter TV replacement remains unexplored in patients with TS. The most efficient way to achieve ventricular pacing in patients after TV replacement needs to be investigated.

Multiple and mixed valvular heart disease:

• Further evaluation of the impact on outcomes and indication for intervention, as well as timing and modalities of intervention, is required.

Prosthetic valves:

• Further development of current prosthetic valve devices is required to address their main complications (e.g. improved tissue processing to reduce degeneration of bioprostheses or new mechanical valve designs to reduce risk of thrombosis).
• Antithrombotic drugs in MHV patients: Whether UFH or LMWH should be preferred as bridging therapy after MHV implantation, as well as their timing and dosage, remains to be established.
• For patients with MHV undergoing major NCS, the optimal post-operative management and bridging of VKA needs further investigation.
• The role of pharmacogenomics for VKORC1, CYP2C9, and CYP4F2 in patients with highly variable INR, and low TTR or major vascular complications despite good adherence, should be further investigated.
• More data on the risks and benefits of slow thrombolysis for valve thrombosis are required.

Pregnancy:

• More data are required on optimal management of anticoagulation in pregnant women with MHVs. Prospective studies comparing different antithrombotic regimens are lacking.

Non-cardiac surgery

• Clinical utility of scales for peri-operative risk evaluation needs to be determined.

Sex-specific considerations:

• The development of sex-adjusted surgical risk prediction tools is required.
• Additional data are needed to validate sex-specific cut-offs indicating interventions.
• Further research is needed to investigate sex-related differences in the prognosis and treatment of specific valve diseases, especially TR.

Commentary:
The 2025 ESC/EACTS Guidelines on Valvular Heart Disease provide a pivotal framework for clinical practice by adopting a multidisciplinary approach to the diagnosis and management of valvular disorders. The guidelines emphasize the role of the Heart Team and Heart Network models, promoting patient-centered decision-making and highlighting the importance of high-volume centers. Additionally, the integration of advanced imaging modalities, including three-dimensional echocardiography, cardiac magnetic resonance, and computed tomography, helps to refine diagnostic criteria and enables more accurate evaluation of valvular pathology.

A key strength of the guidelines is the provision of up-to-date, evidence-based therapeutic strategies for each type of valvular disease. In particular, conditions such as aortic and mitral stenosis or regurgitation are addressed in detail, covering intervention timing, anatomical suitability, left ventricular function, and symptom assessment. The indications and risk assessments for both transcatheter and surgical approaches are clearly defined. Management of anticoagulation in patients with mechanical or bioprosthetic valves, perioperative care, and guidance during pregnancy are also comprehensively discussed.

Nevertheless, several areas remain in need of further research. Specifically, the prognostic impact of left ventricular remodeling in asymptomatic aortic regurgitation, the association between primary mitral regurgitation and ventricular arrhythmias, and the effectiveness of treatment strategies in tricuspid valve disease are not yet fully elucidated. Prospective data on intervention timing and the selection of appropriate strategies in patients with mixed valvular disease remain limited. Moreover, larger cohort studies are needed to better understand the long-term performance of both bioprosthetic and mechanical valves.

In conclusion, the 2025 ESC/EACTS Guidelines on Valvular Heart Disease offer valuable contributions to clinical practice through their multidisciplinary approach, evidence-based recommendations, and incorporation of modern imaging and intervention strategies. Future research, particularly addressing long-term outcomes, management of asymptomatic disease, and the efficacy of transcatheter interventions, will further enhance the clinical applicability and impact of these guidelines.