2025 ESC/EACTS valvular heart disease guidelines: practical updates on mitral and tricuspid regurgitation

European Heart Journal Supplements, vol. 28, pp. iv83–iv96

Abstract

2025 ESC/EACTS guidelines for valvular heart disease reflect the rapid evolution of transcatheter technologies and multidisciplinary care. In primary mitral regurgitation, surgical repair remains the gold standard, with a new Class I recommendation for asymptomatic patients and refined timing incorporating indexed left ventricular end-systolic dimension. Transcatheter edge-to-edge repair (TEER) is upgraded to Class IIa for symptomatic high-risk patients. In secondary mitral regurgitation (SMR), the guidelines distinguish between atrial and ventricular phenotypes. Transcatheter edge-to-edge repair has now a Class I [Level of Evidence (LOE) A] recommendation for very selected patients with ventricular SMR symptomatic despite guideline-directed medical therapy. For atrial SMR, surgery-often involving concomitant atrial fibrillation ablation-is preferred in suitable candidates, while TEER is reserved to high-risk patients. Regarding tricuspid regurgitation, the guidelines emphasize early referral and structured evaluation of right ventricular function and pulmonary pressures (Class I). Transcatheter tricuspid valve interventions are upgraded to Class IIa (LOE A) for symptomatic high-risk patients, provided severe right ventricular dysfunction or precapillary pulmonary hypertension are absent. These updates redefine atrio-ventricular valve management by promoting earlier and personalized intervention. They solidify the role of transcatheter therapies as evidence-based, outcome-modifying options within a Heart Valve Centre framework, while precisely delineating the continued priority of surgery in lower-risk populations and complex anatomies.

Authors 6

1. Marianna Adamo corresponding

   Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia · University of Brescia

   Affiliation as printed

   Cardiac Catheterization Laboratory and Cardiology, ASST Spedali Civili di Brescia , Piazzale Spedali Civili 1, Brescia 25123 ,

   Department of Medical and Surgical Specialties, Radiological Sciences, and Public Health, University of Brescia , Piazza del Mercato 15, Brescia 25121 ,

2. Mauro Massussi

   Azienda Socio Sanitaria Territoriale degli Spedali Civili di Brescia

   Affiliation as printed

   Cardiac Catheterization Laboratory and Cardiology, ASST Spedali Civili di Brescia , Piazzale Spedali Civili 1, Brescia 25123 ,

3. Nina Ajmone Marsan Aachen Department of Cardiology, Leiden University Medical Center

   Leiden University Medical Center

   Affiliation as printed

   Department of Cardiology, Leiden University Medical Center , Albinusdreef 2, Leiden 2300 RC ,

4. Michael Andrew Borger

   Leipzig Heart Institute

   Affiliation as printed

   University Clinic of Cardiac Surgery, Leipzig Heart Center , Leipzig ,

5. Fabien Praz

   University Hospital of Bern

   Affiliation as printed

   Inselspital Universitätsspital Bern , Bern ,

6. Marco Metra

   Vita-Salute San Raffaele University · IRCCS Ospedale San Raffaele

   Affiliation as printed

   Department of Cardiology, IRCCS San Raffaele Scientific Institute , Milan ,

   Vita—Salute San Raffaele University , Milan ,