2025 ESC/EACTS Guidelines for the Management of Valvular Heart Disease

Authors, Journal, Affiliations, Type, DOI

• Chairpersons: Fabien Praz (ESC, Switzerland), Michael A. Borger (EACTS, Germany)
• Journal: European Heart Journal (2025) 46, 4635–4736
• Affiliations: ESC and EACTS Task Force; authors from across Europe, Tunisia, Canada, Israel, and Serbia
• Type: Joint ESC/EACTS Clinical Practice Guideline
• DOI: https://doi.org/10.1093/eurheartj/ehaf194

Overview

The 2025 ESC/EACTS Guidelines replace the 2021 edition and provide updated recommendations for the management of all acquired valvular heart diseases (VHD). Major changes include expanded TAVI indications (asymptomatic AS, BAV stenosis, severe AR in inoperable patients), formal recognition of atrial vs ventricular secondary MR as distinct entities, Class I evidence for TEER in ventricular SMR meeting COAPT-like criteria, new RCT-based recommendations for transcatheter tricuspid valve treatment, and updated antithrombotic therapy guidance. A new dedicated section on sex-specific considerations has been added, and structural valve deterioration definitions have been unified.

Keywords

Guidelines · European Society of Cardiology (ESC) · European Association for Cardio-Thoracic Surgery (EACTS) · Valvular heart disease · Aortic stenosis · Aortic regurgitation · Mitral stenosis · Mitral regurgitation · Tricuspid regurgitation · Tricuspid stenosis · Multivalvular disease · TAVI · SAVR · Heart surgery · Transcatheter edge-to-edge repair · Transcatheter valve replacement

Key Takeaways

Heart Team and Heart Valve Centre

• A multidisciplinary Heart Team working within a regional Heart Valve Network is the standard of care; patients with complex conditions should be referred to high-volume Heart Valve Centres
• Requirements for a Heart Valve Centre include minimum procedural volumes for TAVI, SAVR, MV repair, and complex interventions; complex procedures should be concentrated at the most experienced centres
• Patient-centred shared decision-making is explicitly reinforced throughout the guidelines

Imaging Assessment

• Advanced modalities (3D echocardiography, CCT, CMR) are now central to evaluation; integrative multimodality assessment is recommended for complex scenarios
• CCT is key for TAVI planning: annulus sizing, aortic root anatomy, coronary ostia distance, vascular access, and degree/distribution of valve calcification
• CMR is the reference for accurate LV/RV volumetrics and quantification of regurgitant volumes; particularly useful in borderline or discordant cases
• Strain imaging (GLS) assists in detecting subclinical LV/RV dysfunction before thresholds for intervention are met

Management of Associated Conditions

• CAD: CCTA recommended before valve intervention if pre-test CAD likelihood ≤50%; invasive angiography for >50%; CABG Class I with ≥70% stenosis if undergoing valve surgery; PCI Class IIa before TAVI for ≥90% stenosis in vessels ≥2.5 mm (NOTION-3 trial)
• AF: DOACs preferred over VKA for AS, AR, MR with AF (Class I A); DOACs contraindicated if rheumatic MS with MVA ≤2.0 cm²; surgical LAAO recommended (Class I B) during valve surgery to reduce stroke (LAAOS III); concomitant AF ablation Class I A for MV surgery, Class IIa A for non-MV surgery
• Radiation-induced VHD: Screening TTE 10 years after RT, every 5 years thereafter; operative risk underestimated by standard scores; TAVI preferred for radiation-induced AS; M-TEER limited by leaflet thickening in radiation MV disease
• Cardiogenic shock: TAVI now largely replaces balloon aortic valvuloplasty for decompensated AS in shock; M-TEER supported by propensity data for acute ventricular SMR post-MI

Aortic Regurgitation (AR)

• Evaluation: integrative TTE approach for AR severity; CMR and 3D echo more accurate for LV volumes and LVEF; assess ascending aorta at all levels; strain imaging for subclinical LV dysfunction
• Indications for surgery:
  • Class I: Symptomatic severe AR; asymptomatic with LVESD >50 mm or LVESDi >25 mm/m² or LVEF ≤50%; concomitant with CABG or ascending aorta surgery
  • Class IIa: AV repair at experienced centres when durable results expected; replacement of aortic root/ascending aorta ≥45 mm if AV surgery indicated and risk is low
  • Class IIb (new): TAVI for symptomatic severe AR ineligible for surgery if anatomy suitable; surgery for LVESDi >22 mm/m² or LVESVi >45 mL/m² or LVEF ≤55% at low risk
• Valve-sparing aortic root replacement (VSARR) preferred over Bentall in young patients with root dilatation and good tissue quality at experienced centres
• BAV: symmetry predicts repair durability; aortic dilatation present in 10% of first-degree relatives — echocardiographic screening recommended

Aortic Stenosis (AS)

• Grading: High-gradient AS (mean PG ≥40 mmHg, Vmax ≥4.0 m/s, AVA ≤1 cm²) = severe regardless of flow/EF. Discordant patterns require additional workup (DSE, CCT calcium scoring)
• CCT calcium score: >2000 AU (men) / >1200 AU (women) = severe AS with ~85% sensitivity/specificity
• Symptomatic severe AS: Class I intervention in all eligible patients with high-gradient AS; low-flow low-gradient with reduced LVEF: intervention when confirmed severe (Class I B); low-flow low-gradient with preserved LVEF: intervention when confirmed severe (Class IIa)
• Asymptomatic severe AS (new):
  • Class I: LVEF <50% without other cause
  • Class IIa (new): Early intervention for high-gradient AS with LVEF ≥50% and low procedural risk as alternative to watchful waiting (supported by EARLY TAVR, RECOVERY, AVATAR meta-analysis)
  • Adverse prognostic markers supporting early intervention: very high Vmax (≥5 m/s), severe calcification + Vmax progression ≥0.3 m/s/year, markedly elevated BNP/NT-proBNP (>3× normal), LVEF <55%
• Mode of intervention (TAVI vs SAVR):
  • Heart Team decision based on age, procedural risk, anatomical suitability, lifetime management, and patient preference
  • TAVI non-inferior to SAVR in low-risk patients at 5 years (DEDICATE, PARTNER 3, Evolut Low Risk)
  • BHV recommended for most patients ≥65 years (aortic) or ≥70 years (mitral); MHV considered <60 years (aortic) or <65 years (mitral) with long life expectancy
  • TAVI for BAV stenosis at high surgical risk (Class IIb B, new): if anatomy suitable per Heart Team
• No proven medical therapy to delay AS progression; statins ineffective
• Transthyretin cardiac amyloidosis may coexist — screen with bone scintigraphy if suspected; valve intervention still beneficial despite co-existing ATTR

Primary Mitral Regurgitation (PMR)

• Evaluation: integrative echo (EROA, RVol, vena contracta), CMR for LV volumes and LVEF, genetic evaluation if connective tissue disease or familial presentation
• Indications for intervention:
  • Class I: Symptomatic severe PMR; asymptomatic with LVESD ≥40 mm or LVESDi ≥20 mm/m² or LVEF ≤60%
  • Class I (new): Surgical MV repair in low-risk asymptomatic severe PMR (LVESD <40 mm, LVESDi <20 mm/m², LVEF >60%) when durable repair likely AND ≥3 of: AF, SPAP >50 mmHg, LAVI ≥60 mL/m² or LA diameter ≥55 mm, concomitant ≥moderate secondary TR
  • Class IIa: TEER in high-risk patients not suitable for surgery
  • Class IIb (new): Minimally invasive MV surgery at experienced centres to reduce length of stay and accelerate recovery
• MV repair strongly preferred over replacement; freedom from moderate/severe MR 87.5% at 20 years in expert centres

Secondary Mitral Regurgitation (SMR)

• Atrial SMR (new formal definition): LVEF ≥50%, no/mild LV dilatation, MA AP diameter >35 mm, LAVI >34 mL/m²; driven by AF and/or HFpEF; distinct from ventricular SMR
• Ventricular SMR: Optimised GDMT (ACE-I/ARB/ARNI + BB + MRA + SGLT2i) and CRT (if criteria met) before any MV intervention; ~40% show MR improvement after 1–3 months GDMT
• Ventricular SMR without CAD (intervention):
  • Class I A (upgraded): TEER recommended to reduce HF hospitalisations and improve QoL in haemodynamically stable symptomatic patients with LVEF <50% and persistent severe SMR despite optimised GDMT/CRT, fulfilling specific clinical/echo criteria (COAPT, RESHAPE-HF2)
  • Criteria for TEER (Table 7): NYHA ≥II, LVEF 20–50%, LVESD ≤70 mm, ≥1 HF hospitalisation/year or elevated BNP, SPAP ≤70 mmHg, no severe RV dysfunction, no advanced HF, no CAD requiring revascularisation
  • TEER is non-inferior to MV surgery (MATTERHORN trial); MV surgery Class IIb C if not suitable for TEER
• Atrial SMR (intervention, new):
  • Class IIa: MV surgery + surgical AF ablation + LAAO in symptomatic patients on optimal therapy
  • Class IIb: TEER if ineligible for surgery after rhythm optimisation
• Ventricular SMR with CAD: MV surgery Class I B at time of CABG; PCI + re-evaluate MR Class IIb C

Mitral Stenosis (MS)

• Rheumatic MS: PMC first-line for suitable anatomy (Class I B); MVA ≤1.5 cm² + symptoms or high thromboembolic/haemodynamic risk is indication; VKA (not DOACs) if MVA ≤2.0 cm² and AF
• Contraindications to PMC: LA thrombus, >mild MR, severe or bi-commissural calcification, absence of commissural fusion, severe concomitant AV disease, CAD requiring CABG
• Degenerative MS with MAC: High-risk procedures; TMVI (transcatheter MV implantation) may be considered at experienced centres for symptomatic patients with MAC (Class IIb C, new); mortality remains 10–30% at 1 year

Tricuspid Regurgitation (TR)

• Aetiology: Only 8–10% primary TR; secondary TR classified as atrial (AF/RA dilatation, preserved RV function) vs ventricular (annular dilatation + leaflet tethering from LV/RV disease or PH)
• Evaluation: Integrative echo grading (massive/torrential grading for transcatheter outcomes); RHC mandatory before intervention to assess haemodynamics and exclude pre-capillary PH; CMR for accurate RV volumetrics; TRI-SCORE and STS-TV calculator for risk stratification
• Surgery for TR without left-sided valve disease:
  • Class I C: Symptomatic severe primary TR without severe RV dysfunction or severe PH
  • Class IIa: Asymptomatic severe primary or secondary TR with RV dilatation/dysfunction (but no severe LV/RV dysfunction or PH)
• Concomitant TV surgery with left-sided valve surgery:
  • Class I B (new): Severe primary or secondary TR — TV surgery recommended
  • Class IIa B: Moderate primary or secondary TR — TV repair to prevent progression and RV remodelling
  • Class IIb B (new): Mild secondary TR with annular dilatation (≥40 mm or >21 mm/m²) — TV repair may be considered
• Transcatheter TV treatment (upgraded, new Class IIa A): Improve QoL and RV remodelling in high-risk patients with symptomatic severe TR despite optimal medical therapy, without severe RV dysfunction or pre-capillary PH (TRILUMINATE Pivotal, Tri.Fr, TRISCEND II)

Multiple and Mixed Valvular Heart Disease

• Mixed AV disease (moderate AS + moderate AR): Treat if mean PG ≥40 mmHg or Vmax ≥4.0 m/s regardless of individual lesion severity (Class I B, new); or if asymptomatic with LVEF <50% and Vmax ≥4.0 m/s (Class I C, new)
• Multiple VHD: Staged transcatheter approach preferred (downstream first: aortic → mitral → tricuspid); simultaneous treatment rarely considered
• Concomitant moderate AS at time of other valve surgery: SAVR Class IIa C

Management of Prosthetic Valves

• Valve selection:
  • MHV: Class IIa for patients <60 years (aortic) or <65 years (mitral) with long life expectancy; Class IIa if estimated long life expectancy and no contraindication to OAC
  • BHV: Class IIa for patients >65 years (aortic) or >70 years (mitral); recommended if stable INR unlikely, high bleeding risk, short life expectancy, or planned pregnancy
• Structural valve deterioration (SVD): Definitions unified — moderate SVD: mean PG increase ≥10 mmHg from baseline + absolute mean PG ≥20 mmHg; severe SVD: ≥20 mmHg increase + absolute ≥40 mmHg (aortic)

Antithrombotic Therapy

• Mechanical heart valves (MHV):
  • Lifelong VKA Class I A; INR targets based on valve type, position, and thrombotic risk factors (Table 10)
  • Bileaflet modern aortic MHV + no risk factors: INR 2.5 (range 2–3); with risk factors: INR 3 (2.5–3.5); mitral/tricuspid MHV or old valves: INR 3 (2.5–3.5) or 3.5 (3–4)
  • INR self-monitoring/self-management Class I A (upgraded from IB)
  • DOACs and DAPT Class III A (contraindicated) for MHV
  • ASA addition: Class IIa B for concomitant symptomatic atherosclerotic disease
• After TAVI (no OAC indication):
  • Lifelong single ASA 75–100 mg/day Class I A (POPular TAVI cohort A); long-term ASA after 12 months Class IIa C
  • DAPT not recommended (Class III B); routine OAC not recommended (Class III A) — GALILEO trial halted for harm
• After surgical BHV (aortic, no OAC): VKA or ASA for 3 months Class IIa B; lifelong ASA Class IIb C
• After MV/TV surgical repair: OAC (VKA or DOAC) for 3 months Class IIa B
• Perioperative MHV management: Continue VKA for minor procedures; stop ≥4 days before major surgery, resume within 24 h; bridging with UFH/LMWH for high thromboembolic risk; no bridging may be considered for new-generation aortic MHV without additional risk factors

Non-Cardiac Surgery and Pregnancy

• Severe AS and NCS: Elective NCS should be deferred until AS is treated; TAVI preferred in urgent cases; risk stratification using EuroSCORE adjusted for the procedure type
• Pregnancy: Heart Valve Team including obstetrician, anaesthesiologist, and cardiologist recommended; women with MHV face dilemma of VKA (foetal risk) vs heparin (maternal thrombosis risk); BHV preferred in women planning pregnancy

Sex-Specific Considerations (New Section)

• Women have lower AVA for same AS severity; sex-specific thresholds for LVESD and flow status in AS evaluation
• Women more commonly develop atrial SMR (driven by HFpEF and AF); worse outcomes post-MV repair in some series
• Women underrepresented in VHD trials; sex-specific outcomes after TAVI and SAVR differ

Limitations of the Document

• Most evidence from studies excluding women, elderly patients, and low-income countries; generalisability limited
• RCTs comparing TAVI vs SAVR in younger/lower-risk patients have limited follow-up (≤5 years) — lifetime durability of transcatheter valves uncertain
• Recommendations for multiple/mixed VHD largely based on expert consensus and extrapolation from single-valve data
• Atrial SMR management is primarily observational — no RCT evidence available
• Transcatheter TV options limited by heterogeneous trial populations and short follow-up
• INR target individualisation lacks strong RCT data; relies on observational series and expert consensus

Key Concepts Mentioned

• concepts/Valvular-Heart-Disease — central topic of this guideline
• concepts/TAVI — expanded indications; non-inferior to SAVR in low-risk patients
• concepts/Aortic-Stenosis — grading, symptomatic and asymptomatic management, TAVI vs SAVR decision
• concepts/Aortic-Regurgitation — surgical thresholds, VSARR, new TAVI option
• concepts/Primary-Mitral-Regurgitation — criteria for surgery including new asymptomatic indications
• concepts/Secondary-Mitral-Regurgitation — atrial vs ventricular distinction; TEER Class I A
• concepts/Mitral-Stenosis — PMC criteria, MAC-related degenerative MS, TMVI
• concepts/Tricuspid-Regurgitation — transcatheter treatment upgraded; concomitant TV surgery evidence
• concepts/Heart-Valve-Centre — network model; volume-outcome relationship
• concepts/Structural-Valve-Deterioration — unified definitions for SVD
• entities/Heart-Failure — GDMT in ventricular SMR; cardiogenic shock management
• entities/Atrial-Fibrillation — LAAO, surgical ablation, anticoagulation strategy
• entities/Pulmonary-Hypertension — TR evaluation; TEER contraindicated if severe pre-capillary PH
• entities/ATTR-Amyloidosis — coexists with AS in elderly; valve intervention still beneficial

Key Entities Mentioned

• entities/Atrial-Fibrillation — AF-driven atrial SMR and TR; anticoagulation in VHD
• entities/Heart-Failure — ventricular SMR; cardiogenic shock; GDMT optimisation
• entities/Pulmonary-Hypertension — post-capillary PH in VHD; pre-capillary PH as contraindication to TR intervention
• entities/ATTR-Amyloidosis — co-existing AS; bone scintigraphy screening

Wiki Pages Updated

• Created: sources/vhd-esc-2025
• Updated: wiki/sourceindex
• Updated: wiki/wikiindex
• Created: concepts/Valvular-Heart-Disease
• Created: concepts/TAVI
• Created: concepts/Aortic-Stenosis
• Created: concepts/Aortic-Regurgitation
• Created: concepts/Primary-Mitral-Regurgitation
• Created: concepts/Secondary-Mitral-Regurgitation
• Created: concepts/Mitral-Stenosis
• Created: concepts/Tricuspid-Regurgitation
• Created: concepts/Heart-Valve-Centre
• Created: concepts/Structural-Valve-Deterioration