The newly published European Society of Cardiology guidelines for valvular heart disease (VHD) introduce several key updates that place an emphasis on transcatheter treatment and less surgically invasive options, sex-specific considerations, and the Heart Team.

Since the release of the last guidelines in 2021, several important new studies have been published, particularly randomized controlled trials investigating the treatment of severe aortic stenosis, ventricular secondary mitral regurgitation, and tricuspid regurgitation, according to Fabien Praz, MD, ESC chairperson and an interventional cardiologist with Bern University Hospital in Bern, Switzerland.

“Together, these updates underscore a trend toward earlier, mechanism-driven intervention, broader integration of advanced imaging, and stronger reliance on expert Heart Team decision-making to optimize patient outcomes,” Partho P. Sengupta, MD, DM, a professor at the Robert Wood Johnson Medical School at Rutgers University, in New Brunswick, New Jersey, who was not involved with drafting the guidelines, told Medscape Medical News.

The ESC guidelines, which were developed in conjunction with the European Association for Cardio-Thoracic Surgery, were published in the European Heart Journal and presented at European Society of Cardiology (ESC) Congress 2025.

What’s New

For Praz, the most important new recommendations in the 2025 guidelines expand indications for transcatheter therapies and less invasive surgical options for the treatment of VHD.

Under the new guidelines, clinicians may consider transcatheter aortic valve implantation (TAVI) in symptomatic patients with severe aortic regurgitation deemed ineligible for surgery by the Heart Team. They can also weigh TAVI as a treatment option for patients with symptomatic and asymptomatic severe aortic stenosis and severe bicuspid aortic valve stenosis who are at increased risk for surgical complications. For symptomatic patients with severe atrial secondary mitral regurgitation who are ineligible for surgery, clinicians can now also consider transcatheter edge-to-edge repair after optimization of medical therapy.

All three are class IIb recommendations.

Another new class IIb recommendation states minimally invasive mitral valve surgery may be considered at experienced centers to reduce the length of stay and speed recovery for patients with severe primary mitral regurgitation. And provided no contraindications for long-term anticoagulation therapy exist, a mechanical heart valve should be considered in patients with long life expectancy, according to a class IIa recommendation.

Other additions of note, according to Praz, include a new section on the sex-specific considerations to improve the treatment of women, which address aortic, mitral, and tricuspid valve diseases. The guidelines committee also added a new section on the management of patients with associated cancer or those who are suffering from the consequences of high-dose radiation therapy as well as a section on patients with multiple valve disease or those who are presenting with cardiogenic shock and acute heart failure due to valve lesions.

What’s Revised

The updated guidelines include dozens of revisions to the 2021 publication. Some of the most significant ones are the high-class recommendations for earlier treatment of asymptomatic patients with primary mitral regurgitation and aortic stenosis, according to Praz. He also highlighted the extension of TAVI to patients aged 70 years or older, down from 75 years.

“Transcatheter tricuspid valve treatment has also been upgraded from class IIb with level C evidence to class IIa with level A evidence based on recent randomized controlled trials using both repair and replacement techniques and confirming positive impact on quality of life, right ventricular remodeling, and heart failure hospitalizations,” Praz told Medscape Medical News.

Another noteworthy change is the emphasis on the Heart Team’s evaluation of patients with severe tricuspid regurgitation to determine who would benefit from therapy, according to Alan Zajarias, MD, a co-director at the Center of Valvular Heart Disease at Washington University School of Medicine in St. Louis, who was not involved with drafting the ESC guidelines.

An Individualized Approach

Praz said the guidelines will help move the patient’s goals and preferences to the forefront and promote an individualized mechanism-based approach to treatment, adding that patients with complex disease “should be referred to experienced centers with dedicated expertise and access to a broad range of surgical and minimally invasive treatment options.”

Sengupta added that the new guidelines stress the importance of key strategies such as awareness programs, enhanced public and medical education, the development of simplified and improved diagnostic tools, and initiatives to reduce costs and broaden access to evidence-based treatments.

“This recognition not only validates the need for more equitable approaches to the management of valvular heart disease but also creates opportunities for the integration of innovative technologies,” he said.

Sengupta also highlighted novel technologies that may eventually prove game changing.

“Advances in artificial intelligence combined with wearables, ECG, and point-of-care ultrasound hold great promise for earlier detection and risk stratification, enabling us to identify valvular heart disease in its subclinical stages and intervene more effectively as cardiovascular care moves toward precision medicine,” he said.

A Word on the American College of Cardiology (ACC)/American Heart Association (AHA) VHD Guidelines

Zajarias shared several key distinctions between these new guidelines and the ACC/AHA guidelines for the management of patients with VHD published in 2020. These include a: 

• Class I recommendation for transcatheter edge-to-edge repair in secondary mitral regurgitation
• Recommendation upgrade for TAVI for aortic regurgitation
• Multidisciplinary assessment of patients with severe tricuspid regurgitation
• Recommendation for asymptomatic severe aortic stenosis

“All these recommendations occurred due to more updated information from clinical trials that were published since the last update,” Zajarias said. “The ACC/AHA valve guidelines are due to be updated soon. Be on the lookout.” 

Praz reported receiving travel and meeting support from Abbott Vascular, Edwards Lifesciences, Medira, Polares Medical, and Siemens Healthineers; payment from Abbott Vascular and inQB8 Medical Technologies; and research funding from the department/institution from Abbott Vascular. Sengupta reported no conflicts of interest. Zajarias is a consultant for Anteris, Edwards Lifesciences, and Medtronic.

Brian Ellis is a freelance writer and editor who lives in Southwest Virginia.