ESC 2025 – Valvular Heart Disease (VHD) Guidelines
ESC 2025 – Valvular Heart Disease (VHD) Guidelines
(Medscape, Sept 23, 2025, ESC Congress Madrid). Published in European Heart Journal
1. General Themes
• Stronger focus on transcatheter therapies and less invasive surgery.
• Heart Team emphasized for decision-making.
2. New Recommendations (Class IIb unless noted):
A-Aortic Valve Disease:
• Aortic Stenosis (AS):
• ESC now supports earlier intervention in selected asymptomatic severe AS if:
• Very severe (Vmax ≥ 5 m/s or AVA < 0.6 cm²).
• LVEF < 50% without another cause.
• Abnormal exercise test (hypotension or symptoms).
• Evidence of fibrosis or elevated biomarkers (BNP/troponin).
• TAVI Age Cut-off:
• 2021: ≥75 years.
• 2025: lowered to ≥70 years.
• For low-risk younger patients, surgery remains the preferred option.
• Aortic Regurgitation (AR):
• New option: TAVI may be considered in severe symptomatic AR patients deemed inoperable or high surgical risk.
B-Mitral Regurgitation (MR)
• Secondary (functional) MR:
• ESC 2025: TEER (Transcatheter Edge-to-Edge Repair) is now Class IIb for symptomatic patients despite GDMT (including CRT if indicated) who are not surgical candidates.
• ACC/AHA 2020: TEER carries a stronger Class I recommendation under similar criteria:
• Severe symptomatic MR (NYHA II–IV).
• LVEF 20–50%.
• LV dimension not extremely dilated (LVIDd ≤ 70 mm).
• Unsuitable for surgery.
* Primary MR:
• Earlier surgical intervention even in some asymptomatic cases.
• Minimally invasive mitral surgery at expert centers for severe primary MR.
• Mechanical valves for patients with long life expectancy (Class IIa).
3. Revisions vs 2021 Guidelines
• Earlier intervention in asymptomatic severe AS & primary MR.
• TAVI age threshold lowered → from ≥75 yrs → now ≥70 yrs.
• Tricuspid transcatheter therapy: upgraded to Class IIa, Level A evidence (proven QoL, RV remodeling, reduced HF admissions).
• Heart Team evaluation mandatory in severe TR to decide therapy candidacy.
4. Individualized Care
• Emphasis on patient-centered approach: goals, preferences, comorbidities.
• Referral to experienced centers with full spectrum of options (surgical + transcatheter).
5. Future Directions & Technology
6. Comparison with ACC/AHA (2020 VHD Guidelines)
• ESC 2025 differs in:
* TEER for secondary MR → Class I in ACC/AHA.
* TAVI for AR → upgraded.
* Multidisciplinary assessment for severe TR.
* Recognition of asymptomatic severe AS treatment earlier.
• ACC/AHA update is expected soon.
