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

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.