2025 ESC/EACTS Valvular Heart Disease Guidelines: Practical Updates on Mitral and Tricuspid Regurgitation

Abstract The 2025 ESC/EACTS Guidelines for Valvular Heart Disease reflect the rapid evolution of transcatheter technologies and multidisciplinary care. In primary mitral regurgitation (PMR), 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 (LVESDi). Transcatheter edge-to-edge repair (TEER) is upgraded to Class IIa for symptomatic high-risk patients. A new Heart Team algorithm classifies anatomical complexity to guide selection between TEER, transcatheter mitral valve replacement (TMVR), or conservative care. In secondary mitral regurgitation (SMR), the guidelines distinguish between atrial and ventricular phenotypes. TEER is now a Class I (LOE A) recommendation for ventricular SMR symptomatic despite guideline-directed medical therapy (GDMT). For atrial SMR, surgery—often involving concomitant AF ablation—is preferred in suitable candidates, while TEER is reserved for high-risk patients. Regarding tricuspid regurgitation (TR), the guidelines emphasize early referral and structured evaluation of right ventricular function and pulmonary pressures (Class I). Transcatheter tricuspid edge-to-edge repair (T-TEER) and other therapies are upgraded to Class IIa (LOE A) for symptomatic high-risk patients, provided severe RV dysfunction or precapillary pulmonary hypertension (PH) are absent. These updates redefine atrio-ventricular valve management by promoting earlier, 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.