Highlights: Updates on the ESC/EACTS Guidelines on Valvular Heart Disease

The 2025 ESC/EACTS Guidelines for the Management of Valvular Heart Disease, presented at the ESC Congress in Madrid, introduce significant updates aimed at improving patient outcomes through earlier intervention, refined diagnostic criteria, and expanded treatment options.

In this blogpost, we have prepared the highlights of the updated guidelines – but first, we prepared a short quiz for you to check your knowledge!

A 72-year-old patient with severe symptomatic tricuspid aortic stenosis (mean gradient 50 mmHg, aortic valve area 0.8 cm²) and intermediate surgical risk (STS score 4%) presents to your clinic. The patient has no significant comorbidities except for well-controlled hypertension. According to the 2025 ESC/EACTS Guidelines for the Management of Valvular Heart Disease, which of the statements in the quiz below is most accurate regarding the choice between Transcatheter Aortic Valve Replacement (TAVR) and Surgical Aortic Valve Replacement (SAVR) for this patient?

1. General Trends - Earlier Intervention, New Subtype of Regurgitation, and the Central Role of Shared Decisions

• The updated guidelines advocate for earlier intervention in patients with valvular heart disease. This is true for aortic, mitral, and tricuspid valve pathologies. The shift is supported by robust evidence demonstrating the benefits of timely treatment in preventing disease progression and improving long-term outcomes. 
• There is a new type of valve disease,  that of functional atrial mitral or tricuspid regurgitation. It describes valve leakage (mitral or tricuspid) caused by atrial enlargement and annular dilation while the ventricular geometry and function is not the source of the functional insufficiency of the valves. The treatment therefore differs!
• Shared decision-making and the involvement of a multidisciplinary Heart Team are now more critical than ever. Clinicians are encouraged to engage patients in treatment decisions, aligning choices with individual preferences, and clinical circumstances. The guidelines also highlight the importance of Heart Valve Centers delivering advanced diagnostic imaging and specialized care for complex cases.

2. Aortic Regurgitation: Fine-grained Cutoff Values and Interventional Indications

Key Updates:

• New cutoff values for annuloaortic diameter and volume have been defined impacting AV surgery decisions in patients with asymptomatic severe AR (IIB indication). However they practically only regard patients who previously had borderline measurements. Here’s why: Previously, decision thresholds relied mostly on absolute values like LVESD >50 mm, etc. Now, indexed cutoffs exist: e.g. LVESD indexed (LVESDi) >22 mm/m² or LV end-systolic volume index (LVESVi) >45 mL/m². These updates are especially important for patients with smaller body surface areas and for females, who might not meet previously established thresholds - So keep this in mind!
• Aortic valve repair is strongly recommended for young patients, provided it is feasible and performed in experienced centers.
• For patients with a dilated aortic root, surgery is now recommended when the diameter reaches 45 mm. In such cases, a valve-sparing root replacement is the preferred approach.
• Importantly, for transcatheter aortic valve replacement (TAVR), there is now a Class IIb indication that applies to patients with severe, symptomatic aortic regurgitation who are ineligible for surgery and meet specific morphological criteria.

3. Aortic Stenosis: Simplified Diagnostics and Expanded TAVR Indications

Before moving on to a summary of what changed in the guidelines for aortic stenosis, we have a quiz for you – can you answer correctly?

Diagnostic Changes:

• In low-flow, low-gradient aortic stenosis, dopamine stress echocardiography is no longer mandatory. CT calcium scoring is now considered equally important for establishing a diagnosis. While dopamine stress echo can still assess contractile reserve, its role has diminished.

Interventional Treatment Updates:

• The new guideline gives a Class IIa recommendation for aortic valve replacement (AVR) in asymptomatic severe aortic stenosis if certain high-risk features are present, such as…
  • Aortic jet velocity > 5.5 m/s
  • Mean gradient > 60 mmHg
  • Rapid disease progression
  • Abnormal exercise response
  • Elevated BNP levels
  • Borderline ejection fraction
• The age threshold for TAVR vs. Surgical Aortic Valve Replacement (SAVR) has been lowered from 75 to 70 years, based on long-term data showing favorable outcomes with TAVR for this younger age group.

4. Mitral and Tricuspid Regurgitation: Recognizing Functional Atrial Regurgitation

The guidelines introduce a new focus on functional atrial mitral regurgitation and functional atrial tricuspid regurgitation, which are distinct from regurgitation due to left ventricular dilation. These conditions require tailored management strategies, often involving rhythm control and targeted interventions.

• New cutoff values, indexed to body surface area, have been established to better identify severe cases of mitral and tricuspid regurgitation.
• Transcatheter edge-to-edge repair (TEER) is now a Class I recommendation for symptomatic patients with secondary mitral regurgitation and suitable anatomy, reflecting its proven efficacy.

Conclusion

The 2025 ESC/EACTS Guidelines on valvular heart disease mark a pivotal advancement in the field, integrating the latest research to optimize patient care. For those interested in further details, we provide you with a guidelines-centered online course that helps clinicians stay at the forefront of not only valvular heart disease management, but also plenty of other burning topics in echocardiography and cardiology. Start with the free lectures of our new course, Guidelines in Focus: Echo Essentials for Clinical Practice right away!

Reference:

Praz F, Borger MA, Lanz J, et al. 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). European Heart Journal. 2025:ehaf194. doi:10.1093/eurheartj/ehaf194.