2025 ESC/EACTS guidelines for the management of valvular heart disease

“The new patient-centred ESC/EACTS guidelines for the management of valvular heart disease introduced 28 new recommendations and 50 revised recommendations,” said Dr Fabien Praz (University of Bern, Switzerland) at the start of his talk. He and his colleague Prof. Michael Borger (Heart Center of Leipzig, Germany) highlighted some of the key updates [1].

Two new recommendations were made regarding the diagnosis of coronary artery disease (CAD):

• Omission of invasive coronary angiography should be considered in transcatheter aortic valve implantation (TAVI) candidates, if procedural planning with coronary computed tomography angiography (CCTA) is of sufficient quality to rule out significant CAD (class 2a/level B).
• Percutaneous coronary intervention (PCI) should be considered in patients with a primary indication for TAVI and ≥90% coronary artery stenosis in segments with a reference diameter ≥2.5 mm. (2a/B).

Dr Praz then highlighted new volume cut-off criteria using echocardiography or cardiac MRI for managing aortic regurgitation (AR):

• Aortic valve (AV) surgery may be considered in asymptomatic patients with severe AR and left ventricular end-systolic dimension index (LVESDi) > 22mm/m^2, left ventricular end-systolic (LVES) volume index > 45 mL/m^2 (especially in patients with small body size (BSA < 1.68 m^2), or resting left ventricular ejection fraction (LVEF) ≤55%, if surgical risk is low (2b/B).

A new recommendation regarding the mode of intervention for severe AR is that ‘TAVI may be considered for the treatment of severe AR in symptomatic patients ineligible for surgery, as determined by the Heart Team, if the anatomy is suitable (2b/B).’

Regarding the management of patients with asymptomatic severe aortic stenosis (AS), a new 2a/A recommendation was added: ‘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 procedural risk is low.’ Prof. Borger added another new recommendation in the context of AS: “TAVI may be considered for the treatment of bicuspid aortic valve (BAV) stenosis in patients at increased surgical risk, if the anatomy is suitable (2b/B).”

Two other novel recommendations highlighted by Prof. Borger were:

• Surgical mitral valve (MV) repair is recommended in low-risk asymptomatic patients with severe primary mitral regurgitation (PMR) without LV dysfunction (LVESD < 40mm, LVESDi < 20mm/m^2, LVEF >60%) when a durable result is likely, if at least 3 of the following criteria are fulfilled: atrial fibrillation (AF), systolic pulmonary artery pressure (SPAP) at rest >50mmHg, left atrial (LA) dilatation (left atrial volume index (LAVI) ≥60 ml/m^2/ LA diameter >55 mm), or concomitant secondary tricuspid regurgitation (TR) ≥ moderate (1/B).
• Minimally invasive MV surgery may be considered at experienced centres to reduce hospital stay and accelerate recovery (2b/B).

Finally, Dr Praz noted that new and extended sections were created for specific subpopulations, including patients with cancer receiving radiation therapy, patients with cardiogenic shock and acute HF, patients with multiple and mixed valvular heart disease, and sex-specific consideration in patients with valvular heart disease.

1. Praz F, Borger M et al. 2025 ESC/EACTS guidelines for the management of valvular heart disease. ESC Congress 2025, 29 August – 1 September, Madrid, Spain.

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Posted on 7 November 20257 November 2025