The ‘ten commandments’ for the 2025 ESC/EACTS guidelines for the management of valvular heart disease

Abstract

Several important advances necessitated an update of the previous version of the European Society of Cardiology/European Association of Cardiothoracic Surgery Guidelines for the management of valvular heart disease (VHD).1 The 2025 VHD Task Force aimed to produce a concise, practical, and patient-centered document (Figure 1) to guide clinicians in an era of rapid advancements. The following list of ‘Ten Commandments’ is a brief summary of the full document,2 which readers are encouraged to consult in more detail. Heart Team and Heart Valve Centres: Multidisciplinary Heart Teams taking care of VHD patients should work within a regional Heart Valve Network.3 Patients with complex conditions and those requiring complex procedures with a clear volume-outcome relationship should be managed in expert Heart Valve Centres with on-site interventional cardiology and cardiac surgery departments to attain optimal outcomes. Patient-centered care and shared decision-making: Patients’ preferences and goals should be acknowledged by the Heart Team in a shared-decision making process. While treatment recommendations are based on medical information synthesized by the Heart Team, the final decision is made together with the informed patient, considering goals and preferences (Figure 1). Advanced cardiac imaging: Echocardiography remains the primary method for screening and VHD grading, but the increasing role of cardiac computed tomography and cardiac magnetic resonance is stressed throughout the guidelines. Accurate determination of valvular lesion severity and etiology, as well as assessment of associated cardiac damage and pre-procedural planning, requires a combination of these techniques. VHD-associated conditions: Recommendations regarding the diagnosis and treatment of associated coronary artery disease have been modified, with an increasing role for coronary computed tomography angiography.4 Recommendations for concomitant surgical atrial fibrillation ablation and closure of the left atrial appendage have been upgraded for patients undergoing surgery. Earlier intervention in the disease process: New left ventricle indexed thresholds have been introduced for recommending surgery in patients with asymptomatic AR and primary mitral regurgitation (MR). Patients with asymptomatic severe high gradient aortic stenosis (AS) and a LVEF ≥50% have a new Class IIa Level of Evidence (LOE) A recommendation for early intervention as an alternative to close surveillance.5 Intervention for TR should be performed prior to the onset of significant RV dysfunction. New transcatheter aortic valve intervention (TAVI) insights: The age for recommending TAVI in patients with tricuspid AS has been lowered to 70 years, irrespective of patient risk. Non-transfemoral TAVI may be applied in patients at high risk for surgery with unsuitable femoral access. TAVI is an alternative for AR and bicuspid AS patients who are ineligible for surgery. New indications for primary MR: Surgery remains the procedure of choice for patients with primary MR. Clinical triggers for recommending surgery in patients with asymptomatic MR have been listed in a new Class I LOE B recommendation.6 Transcatheter edge-to-edge repair (TEER) is an increasingly used alternative for high-risk patients with suitable anatomy. Atrial and ventricular secondary MR: For the first time, diagnostic criteria and distinct treatment pathways have been established for atrial and ventricular secondary MR, two patient groups with markedly different etiologies and prognoses.7 The recommendation for TEER in selected heart failure patients (LVEF < 50%) with associated severe ventricular secondary MR has been upgraded to Class I LOE A based on three randomized controlled trials and one meta-analysis.8 Refinements in TR treatment pathways: Recommendations for TR surgery in patients requiring left-sided valvular surgery have been modified based on the results of a randomized controlled trial with focus on patients with moderate or more TR, while repair may be considered in selected patients with mild TR and annulus dilatation.9 Transcatheter intervention should be considered in high-risk patients with severe symptomatic TR despite appropriate medical therapy to improve quality of life and RV remodeling.10 Clinician-friendly section on anticoagulation in VHD: Several new recommendations have been added for oral anticoagulation (OAC) management after mechanical heart valve implantation, including bridging before and after non-cardiac surgery and the role of patient education. The increasing role of direct oral anticoagulants in patients with a biological valve prosthesis and a preexisting indication for OAC is also highlighted. Clinician-friendly algorithms clearly display recommended antithrombotic management after all types of VHD interventions. Patient-centered evaluation for treatment of valvular heart disease (VHD) from the 2025 European Society of Cardiology/European Association of Cardiothoracic Surgery Guidelines for the management of VHD (Praz et al.2) M.B. discloses that his hospital receives speakers honoraria and/or consulting fees on his behalf from Edwards Lifesciences, Medtronic, Abbott and Artivion. F.P. has been compensated for travel expenses from Edwards Lifesciences, Abbott Vascular, Medira, Siemens Healthineers, and InQB8 Medical Technologies and has received a research grant to the institution from Abbott Vascular.

Topics & Concepts