Latest randomised trial evidence has contributed to new joint guidelines from the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) for the management of valvular heart disease, which includes revised age thresholds for transcatheter aortic valve implantation (TAVI), among other major updates.
Launched on the opening day of the ESC’s 2025 Congress (29 August–1 September, Madrid, Spain), the new guideline published in the European Heart Journal replaces a previous iteration of the document released in 2021, reflecting new evidence in the treatment of aortic, mitral and tricuspid valve disease.
The new document also acknowledges the increasing role of advanced imaging techniques, such as 3D echocardiography, cardiac computed tomography (CCT), and cardiac magnetic resonance (CMR) imaging in screening and evaluating patients with valvular heart disease.
Regarding aortic stenosis, the guideline prompts heart teams to consider several factors, including clinical characteristics such as age, estimated life expectancy, concomitant conditions and patient preference, as well as access and valve anatomy, and the potential need for future procedures, when weighing up TAVI or surgical aortic valve replacement (SAVR).
Among the amended recommendations, TAVI has been extended to anatomically suitable patients aged 70 years or older—down from 75 years in the previous version—irrespective of the estimated surgical risk, if the aortic valve is tricuspid.
“The task force felt that this age cut-off better reflects the population of patients that has been included into randomised controlled trials that compare surgical aortic valve replacement with transcatheter aortic valve implantation in a sizeable population across surgical risk, and these trials—if we summarise them in a quick way—show that TAVI is non-inferior at least to surgical aortic valve replacement,” said Fabien Praz (Bern University Hospital, Bern, Switzerland), who co-chaired the joint ESC and EACTS guidelines task force that drafted the document alongside Michael Borger (Leipzig Heart Center, Leipzig, Germany), during a press conference at ESC 2025.
“There is an increasing amount of data from these randomised trials in patients 70 and over demonstrating very good early and mid-term outcomes and therefore we felt comfortable lowering the age limit,” added Borger.
Additionally, for patients with asymptomatic severe high-gradient aortic stenosis, the guidelines establish a new class IIa recommendation encouraging early intervention—albeit agnostic to treatment modality—reflecting new evidence in this area.
“The overall feeling of the taskforce was that the evidence was there for this level of recommendation, but that the overall way the trials were designed in terms of the number of patients included and the endpoints of the trials were not convincing enough to make it a level I recommendation,” commented Praz. “The final decision needs to be made in the heart team.”
The new guidelines also consider advancements made in the treatment of severe primary mitral regurgitation (MR), including a new class Ia recommendation for early surgical repair of asymptomatic patients. The recommendation regarding transcatheter edge-to-edge repair (TEER) in high-risk patients has also been upgraded to class IIa, level B.
In patients with heart failure and symptomatic severe ventricular secondary mitral regurgitation (LVEF <50%) fulfilling specific criteria, TEER has a class I recommendation to reduce heart failure hospitalisations and improve quality of life.
The indication for concomitant tricuspid valve repair in patients undergoing left-sided surgery associated with moderate or severe tricuspid regurgitation has also been reinforced, while transcatheter treatment of the tricuspid valve is considered to improve quality of life and right ventricular (RV) remodelling in high-risk patients with symptomatic severe tricuspid regurgitation (TR).
Outside of valvular heart disease, ESC has also launched new guidelines for the management of myocarditis and pericarditis, bringing them together for the first time in recognition of both as inflammatory diseases with significant areas of potential overlap.
“Inflammatory myopericardial syndrome (IMPS) is an umbrella term that we propose is used during the initial diagnostic process until a final diagnosis is made,” Jeanette Schulz-Menger (Charité Medical University Berlin, Berlin, Germany), a chair on the guideline task force, said. “IMPS ranges from isolated myocarditis to isolated pericarditis through mixed forms with possible reciprocal involvement, such as myopericarditis and perimyocarditis. IMPS is characterised by different stages, which not all patients experience, but an understanding of the respective stages is essential for appropriate therapeutic guidance.”
New guidelines covering cardiovascular disease and pregnancy, meanwhile, promote a shared decision-making approach for pregnancies that are high-risk for an adverse maternal and/or foetal event, moving away from advising women with rare health conditions that make their pregnancy high-risk, (such as vascular Ehlers-Danlos syndrome and pulmonary arterial hypertension), against pregnancy.
Instead, the guidelines recommend that women should receive counselling about the high-risk nature of their pregnancy by a multidisciplinary team, which takes into consideration their genetic background (if applicable), family history and previous vascular events.
A first-ever consensus statement linking mental health and cardiovascular disease has also been launched, calling for greater awareness of the multidirectional relationship between the conditions to improve patient health.
