Viewpoint on the 2025 European Society of Cardiology/ European Association for Cardio-Thoracic Surgery Guidelines on the Management of Valvular Heart Disease

Valvular heart disease (VHD) remains a significant cause of mortality and morbidity worldwide. With an ageing population and increasing prevalence of valvular heart disease, the 2025 European Society of Cardiology/European Association for Cardio-Thoracic Surgery (ESC/EACTS) guidelines on the management of VHD provide a timely update for clinicians aiming to optimise patient outcomes, integrate novel therapies, and address existing knowledge gaps in this complex field.¹

Main Findings

The 2025 guidelines on management of VHD build on the 2021 guidelines and introduce several updates, with an emphasis on precision in diagnostics, earlier intervention and broader use of minimally invasive therapies (Table 1). Key updates are described below.

Strengthened Role of Heart Team and Heart Valve Centres

The guidelines reiterate that decisions should be driven by a multidisciplinary heart team, with a strong emphasis on patient-centred shared decision-making. They further stress that complex cases should be referred to high-volume, specialised and experienced centres. Effort should be placed on continuous review and reporting of procedural activities and clinical outcomes to facilitate prompt and comprehensive heart valve referral network.

Refined Diagnostics and Imaging Guidance

Advanced imaging (3D echocardiography, cardiac CT, cardiac MRI) takes a more central role in defining disease severity, evaluation and follow-up of valvular and extra-valvular involvement, as well as planning and guiding of intervention. An integrative approach, in particular the use of multimodality imaging, is strongly recommended to aid diagnostic confidence when one modality is inconclusive or when additional prognostic information on cardiac remodelling is required to guide the timing of intervention. In addition, new diagnostic criteria have been defined to distinguish atrial from ventricular functional mitral regurgitation, in terms of standardised key morphological characteristics, due to the contrasting implications in prognosis and therapeutic options.

Discussion

The 2025 ESC/EACTS guidelines on VHD reflect a shift toward earlier recognition, more nuanced risk–benefit stratification, and wider deployment of minimally invasive therapies. This is in line with the advancement in imaging techniques, transcatheter therapies and patient engagement in recent years. The guidelines also encourage earlier intervention in select patients (especially asymptomatic ones) before the onset of ventricular and/or atrial dysfunction and atrial arrhythmias to prevent adverse outcomes including irreversible cardiac remodelling. This trend echoes broader shifts towards preventative and proactive interventions across all aspects of cardiology. The stronger mandate for heart teams and valve centres also reflects the mounting evidence of volume-outcome relationship and the complexity of modern interventions.

The guidelines are poised to influence the following practice domains.

Interventional Uptake and Mode of Valve Therapy

Lowering the age thresholds for recommending transcatheter approaches may drive greater use of transcatheter aortic valve implantation and transcatheter mitral or tricuspid interventions, particularly in centres with established structural heart programmes. This shift underscores the growing importance of heart valve centres of excellence, which can provide multidisciplinary evaluation, high procedural quality, and comprehensive lifetime management tailored to each patient’s clinical profile and life expectancy.

Lifetime management is especially critical in younger or lower-risk patients, where considerations extend beyond the immediate procedural outcome to include long-term valve durability, the feasibility of future reinterventions (such as valve-in-valve procedures), and the management of antithrombotic therapy, endocarditis risk, and surveillance imaging over time. Coordinated follow-up within dedicated valve clinics allows for timely recognition of structural valve degeneration, or evolving comorbidities that may influence reintervention strategies.

In the Asia-Pacific (APAC) region, where average life expectancy ranges from about 73 to 84 years – spanning from emerging economies to high-income nations, such as Singapore, Japan and South Korea – the lifetime management strategies will place an even greater importance depending on countries.² If patients are expected to live far beyond their initial valve intervention, the anticipated likelihood of valve durability and reintervention should be emphasised upfront. Shared decision-making with recommendations from the heart team, taking into consideration a patient-centred approach, is central for optimal outcomes. Cultural values, health literacy and socioeconomic factors strongly shape patients’ preferences towards an invasive versus minimally invasive approach, while lifestyle considerations and the need for long-term oral anticoagulation post-mechanical heart valve may have further implications in remote parts of the APAC region, where access to regular monitoring of international normalised ratios is impractical. Therefore, individualised management that incorporates local expertise, procedural infrastructure and patient-centred priorities will be essential to ensure durable results, equitable access, and the sustainability of care across diverse healthcare systems in the region.

Surveillance and Early Intervention

The updated guidelines underscore the importance of proactive surveillance using advanced imaging modalities and timely clinical decision-making. In patients with uncertain or multi-valvular lesions, the integration of multimodality imaging, such as echocardiography complemented by CT or cardiac MRI, can enhance diagnostic accuracy and refine assessment of disease severity. This, in turn, supports earlier referral and intervention for individuals who might previously have been managed conservatively despite having asymptomatic severe or mixed moderate valvular pathologies.

Centralisation of Care

In regions where care for VHD remains fragmented or decentralised, aligning with guideline expectations will require not only the reorganisation of heart valve centres of excellence, but also concerted efforts to strengthen education and training across all levels of healthcare. Enhancing clinician awareness of how to recognise and appropriately triage VHD is critical for timely diagnosis and referral. Equally important are national initiatives to develop streamlined referral pathways and integrated care networks, enabling efficient patient flow from community providers to specialised centres, with established heart team evaluation and valve centre capability. Such coordinated healthcare delivery models are essential to ensure equitable access to advanced diagnostics, multidisciplinary evaluation, and intervention across the region.

Limitations and Knowledge Gaps

In the APAC region, the new guidelines may accelerate adoption of transcatheter therapies and provide options for patients deemed too high risk for surgical intervention previously. However, several challenges remain in adopting these guidelines (Figure 1 ).

Patient Characteristics

Asian patients are often of smaller body habitus, which may affect the applicability of threshold metrics derived largely from Western cohorts. In previous studies for transcatheter aortic valve replacement, it has been shown that Asian patients have lower BMI, leading to smaller aortic valve area and smaller annular dimension.^3,4 Similarly, our colleagues from Taiwan and Japan have recommended a lower cutoff for intervention in patients with moderately severe to severe aortic regurgitation using an indexed left ventricular end systolic volume ≥22 mm/m² rather than 25 mm/m² or an indexed left ventricular end systolic diameter ≥46 ml/m² to avoid excess mortality risk.⁵ In mitral valve pathologies, the presence of smaller atria size could pose unique challenges for mitral edge-to-edge repair.⁶ The paucity of region-specific data, particularly among female patients in the APAC region, underscores the ongoing uncertainty regarding optimal intervention thresholds and the most appropriate timing for surgical or transcatheter treatment. As such, the creation of regional registries and databases on VHD will be pivotal in putting together our experiences and the evidence to inform and guide clinical decision-making, and to improve patient outcomes across APAC.

Availability of Heart Valve Centres/Operator and Institutional Experience

Marked disparities exist in the access to various transcatheter interventions in APAC because of different healthcare finance systems, expertise, and physician awareness and skillset.⁷ Data on the distribution, capacity, and technical capabilities of heart valve centres remain limited, and many institutions lack dedicated heart teams, procedural volume, infrastructure, or advanced imaging capabilities required to support complex transcatheter repair or replacement procedures. An inverse relationship between procedural volume and mortality has been previously reported, underscoring the importance of institutional experience in optimising outcomes.^8,9 These gaps contribute significantly to the heterogeneity in procedural outcomes and patient access across the region. Collaborative efforts involving professional societies, local healthcare authorities and ministries of health are needed to enhance funding, infrastructure, and structured training programmes for both the interventional operators and imagers to support the growth of minimally invasive valve therapies.

Socioeconomic Disparities

Socioeconomic variation further compounds inequities in access to transcatheter therapies within the APAC region. Device costs remain high, and reimbursement frameworks differ substantially across different healthcare systems. Government-subsidised programmes are available only in select countries such as Japan, South Korea, Singapore and Australia, whereas lower-income nations often face greater barriers to advanced and high-cost transcatheter therapies.¹⁰ Previous analyses have highlighted a disproportionate distribution of transcatheter aortic valve replacement programmes, with 137 centres in Japan compared to only 120 across the rest of Asia, underscoring the imbalance in regional development and uptake of transcatheter therapy.¹⁰ As such, resource-limited countries often lack access to high-cost transcatheter therapies, and consequently have less opportunity for advanced procedural and imaging training, with limited ability to maintain hybrid catheter laboratories and experienced heart valve teams, thereby widening the gap in procedural equity and outcomes, creating a vicious cycle phenomenon.

Conclusion

The 2025 ESC/EACTS guidelines on VHD represent a road map that aligns with technological progress and evolving clinical expectations. They emphasise earlier, more precise diagnosis and expand the safe envelope for less invasive interventions, while reaffirming the principle of shared, patient-centred decision-making guided by specialised heart teams.

For APAC, the guidelines represent both an opportunity and a challenge. In well-equipped centres, their implementation has the potential to accelerate advances in structural heart disease care. However, meaningful translation into clinical practice will depend on the ability of local societies and institutions to contextualise these recommendations through validation of threshold criteria in regional populations, adaptation of workflows to local clinical realities, investment in workforce training and infrastructure, and the mitigation of cost and accessibility barriers. In the absence of coordinated and sustained efforts to address these challenges, adoption of the guidelines is likely to remain limited and uneven across the region.