ESC/EACTS Release New Valvular Heart Disease Guidelines

Earlier, less-invasive treatment is at the core of the latest iteration of the joint European Society of Cardiology/European Association for Cardio-Thoracic Surgery (ESC/EACTS) valvular heart disease (VHD) guidelines, released last week at the ESC Congress 2025 in Madrid, Spain.

Notably, the document lowers the age cutoff to recommend TAVI over SAVR and stresses patient education, especially regarding anticoagulation.

While previous iterations of these guidelines, including those released in 2021, placed patients at the center of decision-making for VHD treatment, both the ESC chairperson Fabien Praz, MD (Bern University Hospital, Switzerland), and the EACTS chairperson Michael Borger, MD, PhD (Leipzig Heart Center, Germany), told TCTMD the new paper even more strongly emphasizes the importance of patients learning even more about their conditions, treatment options, and follow-up care.

“When we’re talking about lifetime management of aortic stenosis or even mitral disease more and more in the future, I really think there is a knowledge gap there in how well patients understand this information and how they process it and how that affects their decision-making,” Borger said. “If we do more and more shared decision-making and more and more patient-centered care, we have to also understand how patients make decisions. And that scenario is still a relative black box within the cardiovascular community.”

He highlighted that the guideline is the first to include a recommendation for patient education on oral anticoagulation in those receiving mechanical valves (class I, level of evidence A).

The document also further defines specifications for specialized heart valve centers and lists the most complex procedures that should be ideally performed at them in a “more precise” fashion, according to Praz. “We put quite a lot of emphasis on the volume-outcome relationship,” he said.

Borger noted continued support for the heart team as well.

TAVI Recommendations

The “most controversial recommendation” in the latest guideline, according to Borger, is likely the adjustment of the age cutoff for TAVI and SAVR to 70 from 75 years (class I, level of evidence A for TAVI and B for SAVR). “That certainly is something that’s a sensitive subject, especially amongst the cardiac surgery community,” he acknowledged.

This choice is supported by evidence from the investigator-initiated DEDICATE-DZHK6 trial as well as an increasing number of patients between 70 and 75 years old in the low-risk TAVI versus SAVR trials, he said. “Of course, we need longer follow-up, but we thought that there needed to be a reflection of the increasing amount of data in patients between 70 and 75.”

While age should be considered an important criterion for decision-making in these patients, it’s “not the only one,” Praz said. “You need to think: ‘What is the age of the patient? What is the potential life expectancy? If the patient needs a second procedure, what is the risk of the second procedure?’ I think it’s a combination. Age is an important factor, . . . but then you need to look at several other factors.”

With regard to patients with asymptomatic severe aortic stenosis, the strength of the recommendation did not change for TAVI if the procedural risk is low (class IIa, level of evidence A), but the wording was altered slightly to lower the LVEF cutoff to ≥ 50% and say it should be considered “as an alternative to close active surveillance.”

“There was hope among some members of the community that we would come up with a level I recommendation for asymptomatic aortic stenosis, and we just didn’t feel that the evidence was clear enough to make that step,” Borger explained, adding that the writing committee had “methodological reservations” regarding the endpoints in the EARLY TAVR and TAVR UNLOAD trials.

Praz argued that a IIa recommendation is “very liberal” for these patients, especially given the remaining questions about valve durability. Who gets TAVI will often depend on where they live, he said, adding that some hospitals do a great job at surveilling these patients and keeping them stable for longer. “In some other geographies, [follow-up] may be less strict,” he noted, “And in that situation, early treatment could also be an option to avoid any adverse events that can happen later.”

Regardless, Praz continued, “this recommendation clearly opens the door for early treatment in, I think, a balanced and nice way.”

The document also includes new recommendations for TAVI for aortic regurgitation in patients ineligible for surgery (class IIb, level of evidence B) and use of coronary computed tomography angiography (CCTA) to rule out CAD in TAVI candidates (class IIa, level of evidence B). CCTA also now has an upgraded class I, level of evidence B, recommendation to be used before all valve interventions in patients with a moderate or lower pretest likelihood of obstructive CAD.

Adoption of CCTA has varied between European centers in recent years despite the evidence supporting it, especially from DISCHARGE, according to Borger. “We’ve already in Leipzig, for example, moved to that several years ago,” he said. “But in many heart centers, they’re still following the recommendations from the old guidelines, basically saying that anybody over 40 or postmenopausal women should all be getting invasive coronary angiography, and the evidence really doesn’t support that stance anymore.”

Mitral, Tricuspid Interventions

The document also offers new guidance in other realms of valvular disease outside the aorta. Borger highlighted a new class I, level of evidence B, recommendation for surgical mitral valve repair in asymptomatic patients with severe primary mitral regurgitation (MR) provided that certain criteria are met. Additionally, he noted a new class I, level of evidence A, recommendation for transcatheter edge-to-edge repair (TEER) in patients with severe ventricular secondary MR without CAD to reduce heart failure hospitalizations and improve quality of life.

“We also very clearly defined atrial secondary mitral regurgitation for the first time out of any guidelines or consensus documents that I know of,” Borger said. “There’s been a lot of different definitions in the past, so I’m kind of hoping that this is going be the standard going forward.”

For these patients, the guidelines recommend surgery (class IIa, level of evidence B) as well as TEER (class IIb, level of evidence B) for those not eligible for surgery.

Minimally invasive mitral valve surgery also received a new class IIb, level of evidence B, recommendation at experienced centers with the goal of reducing hospital stays. “It’s the first time we’ve had such a recommendation,” Borger said.

“There’s a lot of progress actually for earlier treatment of valvular heart disease, but also less invasive,” Praz noted. He added that the chapter on tricuspid regurgitation (TR) shows the progress made there, with transcatheter treatment being upgraded to a class IIa, level of evidence A, recommendation for improving quality of life in patients with severe TR without left-sided VHD requiring surgery.

Lastly, Praz pointed out important sections in the document regarding patients with multiple types of valvular disease, cancer, cardiogenic shock, and acute heart failure, as well as one describing sex-specific considerations with updates made to the treatment of pregnant patients.

‘Guidelines Are Not Everything’

Commenting for TCTMD, Eric Van Belle, MD, PhD (Lille University Hospital, France), said the updates made to the guidelines are “very important,” most notably the change in the age cutoff for TAVI versus SAVR.

However, he pointed to recent data from the ESC and European Association of Percutaneous Cardiovascular Interventions (EAPCI) showing that valve procedures only make up 6% of annual interventional cardiology practice in Europe and VHD practice varies depending on gross national income.

“You can make the best guideline possible to help people to provide treatment, but [remember] that these treatments have cost and not everyone can afford it,” Van Belle said. “Additional initiatives are needed to decrease the disparities. Guidelines are not everything.”

Borger said he was surprised that VHD practice accounted for such a low percentage of European interventional cardiology practice. “But I can tell you for sure that the interest in valvular heart disease was palpable in Madrid with literally standing-room-only crowds for every one of our presentations,” he said. “We had four related sets of presentations and every one of them [had] overflow. They were turning people back.”