The 2025 European Society of Cardiology/European Association of Cardiothoracic Surgery joint guidelines for the management of valvular heart disease: Revolution or evolution?

The 2025 European Society of Cardiology (ESC)/European Society of Cardiothoracic Surgery guidelines for the management of valvular heart disease (VHD), presented at the ESC Congress in Madrid, update the 2021 document and respond to the rapid growth of evidence from randomized trials, meta-analyses, and large registries. Developed by a multidisciplinary Heart Team including patient representatives, the guidelines emphasize patient-centered "lifetime" management, shared decision-making, and treatment at high-volume expert Heart Valve Centers, especially for complex surgical and transcatheter procedures. The scope has been broadened to address cancer and radiation-associated VHD, cardiogenic shock and acute heart failure, multiple and mixed VHD, and sex-specific issues. Key changes in indications for imaging, treatment, and follow-up of VHD are discussed in the perspective of evidence-based medicine. Key updates include earlier intervention in severe, high-gradient, asymptomatic aortic stenosis, refined age thresholds favoring transfemoral transcatheter aortic valve implantation, and its use in bicuspid aortic stenosis and aortic regurgitation in high-risk or inoperable patients. Recommendations for secondary mitral regurgitation (MR) distinguish atrial from ventricular mechanisms and upgrade mitral transcatheter edge-to-edge repair to class I in selected cases of ventricular secondary MR. At the same time, surgery remains first-line for primary MR, with defined triggers for early repair and emerging roles for transcatheter edge-to-edge repair and transcatheter mitral valve implantation in high-risk patients. The document also strengthens guidance on tricuspid interventions, structured assessment of right ventricular dysfunction, and simplifies antithrombotic strategies, including restricted use of dual antiplatelet therapy after transcatheter aortic valve implantation in patients without another indication for oral anticoagulation. Implementing these recommendations should streamline care pathways and reduce the burden of VHD.