The 2025 practice guidelines on the management of patients with valvular heart disease of the European Society of Cardiology (ESC) and the European Association of Cardio-Thoracic Surgery include new and updated recommendations informed by the evidence provided by several landmark randomized clinical trials and large multicenter registries.1 This commentary examines the potential application and impact of these new recommendations on current clinical practice in Spain.

The current guidelines highlight the importance of a patient-centered and multidisciplinary approach, with a particular focus on understanding the etiology and underlying mechanisms of valve dysfunction through complementary and comprehensive multimodality imaging. Echocardiography remains the first-line imaging modality to evaluate the hemodynamic consequences of valve disease. However, the guidelines acknowledge the superior accuracy of cardiovascular magnetic resonance (CMR) and computed tomography (CT) in assessing these parameters, which are essential for decision-making. Although the guidelines recognize that intervention thresholds based on left ventricular (LV) remodeling differ when LV measurements are obtained by CMR, the specific cutoff values still mainly rely on echocardiography. The document also encourages the establishment and strengthening of heart valve teams, heart valve centers, and heart valve networks to ensure the delivery of personalized therapy for every patient with valvular heart disease.

In the current revision, the recommendations for surgical intervention in chronic severe aortic regurgitation (AR) have been further refined, integrating symptoms, LV function, aortic dimensions, and operative risk into a more detailed framework. Symptomatic patients continue to require surgery regardless of LV ejection fraction (LVEF) (class I, level B), and concomitant valve surgery during other cardiac procedures remains advised (class I, level C). Among asymptomatic patients, the traditional thresholds (LVEF ≤ 50%; LV end-systolic diameter [LVESD]> 50mm, or LVESD index [LVESDi]> 25mm/m2) are reaffirmed (class I, level B). However, the update favors earlier intervention in low-risk patients with subclinical LV dysfunction (LVESDi> 22mm/m2, LVESVi> 45mL/m2, or LVEF ≤ 55%), supported by observational evidence (class IIb, level B). Additional red flags (marked or progressive LV dilatation and declining systolic function) should prompt consideration of surgery, and exercise testing is reserved for borderline cases, particularly asymptomatic patients who do not yet meet surgical criteria. Evidence supporting aortic valve repair has strengthened, resulting in an upgraded recommendation (now class IIa, level B) for selected patients treated in experienced centers. The Ross procedure is recommended for the first time in selected cases, particularly in young patients. Transcatheter aortic valve implantation (TAVI) is introduced as an option only for non-surgical candidates (class IIb, level B), enabled by the availability of new devices specifically designed to treat AR.

Despite these advances, several evidence gaps persist. Risk stratification in asymptomatic patients still relies heavily on surrogate imaging markers, and there is a continued absence of randomized controlled trials comparing early surgery with watchful waiting. Elderly patients and those with significant comorbidities remain underrepresented in clinical studies. Moreover, although thresholds for LV remodeling indicating surgery have been lowered for young, low-risk patients, the overall strength of evidence supporting these earlier interventions is still limited.

The 2025 ESC guidelines reaffirm echocardiography as the cornerstone for diagnosing severe aortic stenosis (AS) while emphasizing an integrated assessment that includes pressure gradients, aortic valve area, flow state, and LV function.

The guidelines clarify the categorization of low-flow states, endorse sex-specific stroke volume thresholds, and highlight the incremental value of CT aortic valve calcium scoring for confirming AS severity in patients with discordant gradients and valve area. Although the use of dobutamine stress echocardiography is advocated, both surgical aortic valve replacement (SAVR) and TAVI are recommended regardless of the presence or absence of flow reserve.

In asymptomatic patients with severe AS, risk stratification is encouraged using novel techniques such as LV global longitudinal strain, staging of extravalvular cardiac damage, biomarkers, and exercise testing. The indication for aortic valve replacement in asymptomatic patients with severe AS and preserved LVEF (≥ 50%) has been upgraded to class IIa, level A, supported by 4 randomized trials and one meta-analysis.2–6

Recommendations regarding the mode of intervention have been refined, expanding the indications for TAVI to younger patients and specific anatomies. The current guidelines lower the age limit from 75 to 70 years (class I, level A). TAVI may also be considered in selected patients with bicuspid aortic valve anatomy and high surgical risk (class IIb, level B). Furthermore, nontransfemoral TAVI has been upgraded from class IIb to class IIa, reflecting robust evidence of its superiority over transapical TAVI and its increasing acceptance for patients unsuitable for surgery or transfemoral access. Importantly, beyond procedural selection, the guidelines highlight the importance of incorporating patient preferences into decision-making.

The document also reinforces the concept of “lifetime management”, emphasizing valve durability, the feasibility of future interventions, anticoagulation needs, and patient preferences.

Despite these updates, notable evidence gaps persist. Long-term durability of TAVI beyond 10 years remains insufficiently defined; optimal postprocedural antithrombotic strategies are uncertain; and evidence is limited for specific clinical contexts such as complex coronary artery disease or multimorbidity. Moreover, the lowered age threshold for TAVI and the upgraded recommendation to use cardiac CT for assessing AS severity and coronary artery disease (now class IIa, replacing invasive coronary angiography) will likely lead to a substantial increase in demand for this imaging modality, which is an important consideration for our health care system.

Timing of intervention in primary mitral regurgitation (MR) is one of the most notable updates in the current guidelines, which clearly favor earlier intervention to improve long-term outcomes. In asymptomatic patients with severe primary MR and preserved LV function, surgical mitral valve repair is recommended (class I) when at least 3 of the following criteria are present: atrial fibrillation, pulmonary hypertension at rest (> 50mmHg), severe left atrial dilatation (left atrial indexed volume ≥ 60mL/m2 or diameter ≥ 55mm), or concomitant moderate or severe tricuspid regurgitation (TR). If fewer than 3 of these criteria are met, surgical mitral valve repair carries a class IIa recommendation in asymptomatic patients. Importantly, the guidelines emphasize that these recommendations apply only to surgical teams with demonstrated durable repair outcomes and very low operative mortality. In addition, minimally invasive mitral valve repair is now incorporated as an option in experienced centers to improve recovery time (class IIb, level B).7 The guidelines also highlight the importance of continuous monitoring, evaluation, and reporting of clinical outcomes and patient-reported outcome measures, supplemented by both local and external audits.

The most noteworthy innovation in the management of secondary mitral regurgitation (SMR) is the formal distinction between ventricular and atrial SMR. This differentiation reflects their distinct anatomical and pathophysiological mechanisms and has direct implications for patient evaluation, prognosis, and therapeutic strategy. The guidelines now provide specific echocardiographic and clinical criteria for classifying both entities.

Assessment of SMR must be performed under guideline-directed medical therapy following hemodynamic optimization. The rapid uptitration of the standard heart failure regimen (known as the “4 pillars”) is emphasized as the first therapeutic step. Approximately 40% of patients with ventricular SMR experience meaningful improvement after 1 to 3 months of optimized medical therapy, highlighting the need for careful reassessment before considering interventional procedures.

For ventricular SMR, new evidence from extended follow-up of 3 randomized clinical trials has been incorporated. Although a pooled meta-analysis of these trials has not demonstrated a survival advantage at 24 months compared with guideline-directed medical therapy, transcatheter edge-to-edge repair (TEER) has consistently shown improvements in quality of life and reductions in heart failure hospitalizations.8 Based on these findings, TEER has been upgraded from class IIa to class I, level A in symptomatic patients without significant coronary artery disease, with LV dysfunction, and meeting the specific echocardiographic and clinical criteria associated with procedural success. The potential indication for surgery remains unchanged (class IIb, level C), given the high surgical risk commonly associated with the underlying pathology in ventricular SMR and the limited evidence supporting a mortality benefit.9

In atrial SMR, the guidelines propose a differentiated strategy. In patients who remain symptomatic despite guideline-directed medical therapy, mitral valve surgery combined with surgical atrial fibrillation ablation and left atrial appendage occlusion (when indicated) should be considered (class IIa). When surgery is not feasible due to high operative risk, TEER may be considered (class IIb).

A practical consequence of these updates is that all patients with SMR should now be systematically classified as having atrial or ventricular SMR before multidisciplinary heart team discussion, enabling personalized therapeutic management. This paradigm shift is expected to result in a substantial increase in TEER procedures for ventricular SMR, reflecting the robust, evidence-based clinical benefits observed in this patient subgroup.

Similarly to SMR, the guidelines recognize 2 subtypes of secondary TR: atrial and ventricular TR. However, therapeutic recommendations are not yet tailored to this classification. Instead, the guidelines emphasize a comprehensive diagnostic approach, integrating echocardiographic and invasive parameters to determine the underlying mechanism (primary, secondary, or device-related TR) and to define right ventricular (RV) dilatation and remodeling using updated reference values. When precise quantification of RV dimensions, function, or volumes is required for clinical decision-making, CMR is specifically recommended owing to the limitations of echocardiography.

An important addition in the current guidelines is the recommendation to use a dedicated heart team and validated risk scores, such as TRI-SCORE and the STS isolated tricuspid valve surgery calculator, for the management of patients with severe TR.

In patients undergoing surgery for left-sided heart valve disease with concomitant severe (class I) or moderate (class IIa) TR, the recommendation to perform tricuspid valve repair has been strengthened based on randomized clinical trial data,10 which demonstrate prevention of disease progression and adverse RV remodeling. In contrast, in patients with only mild TR but with annular dilatation (≥ 40mm or> 21mm/m2), the recommendation is downgraded to class IIb.

In patients with severe TR who do not require left-sided valve intervention, the guidelines weigh the data from 3 randomized trials demonstrating the benefits of TEER and transcatheter tricuspid valve implantation.11–13 Although no separate recommendations are provided for these 2 techniques, transcatheter tricuspid valve intervention is recommended (class IIa, level A) in patients with symptomatic severe TR without concomitant left-sided valve disease requiring surgery, with the goals of improving quality of life and promoting favorable RV remodeling.

The main innovations in recommendations for intervention and/or type of intervention in severe valvular heart disease are summarized in table 1.

The current guidelines highlight the increasing prevalence of multiple valvular heart disease (more than 1 native valve affected) and mixed valvular heart disease (coexisting stenosis and regurgitation of the same valve). In high-income countries, the main etiology of multiple and mixed valvular disease is degenerative, while in middle- and low-income countries, rheumatic heart disease remains the leading cause. The heterogeneity of multiple and mixed valvular heart disease makes it difficult to design randomized clinical trials that could provide high-quality data and support robust recommendations. As a result, the lack of evidence prevents the task force from proposing explicit recommendations for each potential combination of valve lesions. For the first time, however, the guidelines include recommendations for multiple valvular heart disease that align with those for isolated severe valve dysfunction. In addition, there are 2 class I recommendations for intervention in patients with mixed moderate aortic valve disease when the mean transvalvular gradient is ≥ 40mmHg and the peak velocity is ≥ 4 m/s, even when the aortic valve area is> 1cm2. Intervention is recommended when symptoms are present (class I, level B) or when asymptomatic LVEF <50% is present without another identifiable cause (class I, level C). These updates reflect a shift toward earlier intervention in aortic valve disease.

The guidelines provide a detailed table describing the diagnostic challenges of multiple and mixed valvular heart disease. The advent of transcatheter therapies offers new potential alternatives for the management of multiple valvular disease in terms of both the type of intervention and the timing of treatment (staged procedure vs all-at-once approach). However, the guidelines do not address this aspect in detail and instead refer the decision to the Heart Valve Team for a tailored, patient-specific strategy.

In the section on prosthetic valves and antithrombotic therapy, the guidelines introduce new recommendations regarding the continuation of vitamin K antagonists in patients with mechanical heart valve prostheses who undergo minor or minimally invasive procedures (class I, level A). In contrast, dual antiplatelet therapy is not recommended to prevent thrombosis after TAVI.

The need to involve patients in decision-making is clearly emphasized in the current guidelines, which include 2 patient representatives in the Guidelines Task Force for the first time. Central to shared decision-making is the requirement to provide patients with clear, balanced, and unbiased information. Specialized nurses play a key role in improving patient education and communication, as well as coordinating diagnostic tests and management steps. The introduction of new transcatheter and surgical techniques further stresses the importance of multidisciplinary teams led by an experienced heart team. These teams are considered to include clinical cardiologists with expertise in advanced cardiovascular imaging, cardiac surgeons, and interventional cardiologists, in addition to other professionals when complex decisions are required. The guidelines also identify specialized nurses as essential members of these teams because of their roles in patient education and in coordinating the patient pathway. In the specific context of antithrombotic treatment in patients with mechanical valves, proper patient education has been shown to significantly improve treatment quality and adherence to anticoagulation (class I, level A). To better assess patient perceptions throughout the diagnostic and therapeutic process, the guidelines recommend the development of studies focused on patient-reported outcome measures to evaluate quality of life and satisfaction, as well as the use of validated patient-reported outcome measure questionnaires.

In summary, the current guidelines on valvular heart disease promote intervention at earlier stages and emphasize management in specialized heart valve centers with active shared decision-making involving patients (figure 1). As a result, health stakeholders will need to adapt organizational structures to ensure timely access to care and continuous quality monitoring in the management of valvular heart disease. This shift will also fuel ongoing discussions regarding who should manage and treat these patients, what training and competencies are required, and which centers have the necessary capabilities and systems for continuous quality control. Policymakers also have an essential role and should align healthcare planning and resource allocation with the directions set by the guidelines.

Figure 1.

Central illustration.

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None.

No artificial intelligence was used to generate the content of this article.

The conflict-of-interest declaration documents for all authors are available in the supplementary data.