Mitral Valve Disease in 2025: Evolving Treatment Pathways from ESC Guidelines and TCT Advances
Mitral Valve Disease in 2025: Evolving Treatment Pathways from ESC Guidelines and TCT Advances
Sources: TCT 2025 Conference, October 29 2025-Medscape Medical News | ESC/EACTS Guidelines for Valvular Heart Disease ,Eur Heart J. 2022
1. Overview
Mitral valve disease — either mitral regurgitation (MR) or mitral stenosis (MS) — remains a leading cause of heart failure and mortality worldwide.
Recent transcatheter technologies presented at TCT 2025 have expanded treatment possibilities for elderly or high-risk patients once considered inoperable.
2. Treatment Overview
• Surgical repair remains the gold standard for mitral valve disease whenever feasible and safe, providing the most durable correction and best long-term survival.
• When surgery is not possible because of high operative risk or complex anatomy, transcatheter options such as TEER (edge-to-edge repair) or TMVR (transcatheter replacement) offer effective, less-invasive alternatives supported by recent ESC guidelines and TCT 2025 findings.
3. Mitral Regurgitation (MR): Treatment Options
1. Medical Therapy
• Guideline-directed therapy for heart failure (ACE inhibitors/ARBs/ARNIs, beta-blockers, SGLT2 inhibitors, diuretics).
2. Surgical Repair or Replacement
• Repair preferred in primary MR when durable.
• Replacement (mechanical or bioprosthetic) when repair is not feasible.
3. Transcatheter Edge-to-Edge Repair (TEER)
• Definition: Minimally invasive catheter technique joining the mitral leaflets to reduce regurgitation.
• Devices: MitraClip (Abbott) and Pascal (Edwards).
• Approach: Via femoral vein → transseptal puncture.
• Indication: Severe primary or secondary MR with high surgical risk or inoperable status.
• Evidence: COAPT and MITRA-FR trials showed reduced HF hospitalizations and mortality.
• Guideline status: Class I/IIa recommendation in ESC 2021.
4. Transcatheter Mitral Valve Replacement (TMVR)
• For patients unsuitable for surgery or TEER due to anatomy or severe calcification (MAC).
• Devices: Tendyne (Abbott) and Sapien M3 (Edwards).
• TCT 2025 trials (SUMMIT-MAC, ENCIRCLE) showed major improvements in survival and symptoms at 1 year.
5. Adjunctive Therapies
• Cardiac resynchronization therapy (CRT) for functional MR.
• Atrial fibrillation control and anticoagulation as indicated.
4. Mitral Stenosis (MS): Treatment Options
1. Medical Management
• Symptom control with diuretics, rate control (in AF), and anticoagulation to prevent embolism.
2. Percutaneous Balloon Mitral Valvotomy (PBMV / PTMC)
• First-line for rheumatic MS with pliable leaflets and no significant MR or thrombus.
3. Surgical Commissurotomy or Valve Replacement
• For non-pliable or heavily calcified valves, or associated valvular disease.
4. Transcatheter Mitral Valve Replacement (TMVR)
• New option for severe calcification (MAC) or prohibitive surgical risk; Tendyne approved (FDA 2025).
5. Mitral Annular Calcification (MAC)
• Chronic calcium deposition stiffens the mitral annulus → mixed stenosis and regurgitation with heart failure and arrhythmia.
• Common in elderly women with hypertension, diabetes, or renal disease.
• Surgery often impractical; TMVR (Tendyne) now offers a lifesaving alternative.
6. Key Takeaways
• Surgical repair remains the preferred and most durable option when feasible.
• TEER is the main transcatheter solution for high-risk MR.
• TMVR (Tendyne, Sapien M3) is transforming care for inoperable or calcified valves.
• Balloon valvotomy remains first-line for rheumatic MS.
• Heart Valve Team decision-making and advanced imaging are vital for optimal outcomes.
• TCT 2025 results mark a turning point toward effective, less invasive mitral valve therapy for “no-option” patients.
