Management of Valvular Heart Disease: ESC/EACTS 2025, Intervention Thresholds
What Changed in the 2025 Approach
ESC/EACTS 2025 maintains the principle: the decision on intervention for valvular disease is based not only on the degree of regurgitation or stenosis but also on symptoms, ventricular function, pulmonary hypertension, valve anatomy, expected durability of the result, and procedural risk. A practically important change is the earlier discussion of intervention in asymptomatic patients with severe disease if objective markers of decompensation appear.
For the ultrasound diagnostician, this means the report should answer three questions. First, is the defect truly severe? Second, are there signs of impact on the ventricles, atria, and pulmonary pressure? Third, is the anatomy suitable for surgical repair, replacement, or transcatheter correction?
Imaging: What Should Be in the Protocol
The basis remains transthoracic Echo. Transesophageal Echo, especially 3D, is needed for the mechanism of mitral and tricuspid regurgitation, assessment of leaflets, commissures, calcification, and planning of repair or TEER. CT is mandatory when planning TAVI, assessing the aortic annulus, vascular access, calcification, and risk of coronary obstruction. MRI is used when Echo provides conflicting quantitative assessments of regurgitation or ventricular volumes.
Aortic Stenosis: Echo Criteria for Severity
In aortic stenosis, ESC/EACTS 2025 emphasizes the need for an integrated assessment: Vmax, mean gradient, valve area, indexed stroke volume, ejection fraction, and valve calcification. Isolated AVA without verifying LVOT measurement and flow should not be the sole basis for referral for intervention.
| Indicator | Threshold in Guidelines | Clinical Significance |
|---|---|---|
| Vmax through aortic valve | ≥4.0 m/s | Criterion for severe high-gradient AS |
| Mean gradient | ≥40 mmHg | Criterion for severe high-gradient AS |
| AVA | ≤1.0 cm² | Criterion for severe AS |
| Indexed AVA | ≤0.6 cm²/m² | Useful in extreme body sizes |
| SVi | ≤35 ml/m² | Low flow in low-gradient AS |
| Very severe AS | Vmax ≥5.0 m/s or mean gradient ≥60 mmHg | Factor favoring early intervention in asymptomatic patients |
When to Intervene in Aortic Stenosis
Symptomatic severe aortic stenosis is an indication for valve replacement if the intervention is not futile. Symptoms should correlate with the severity of the defect: dyspnea, angina, syncope, reduced exercise tolerance. In questionably asymptomatic patients, a stress test is important: the appearance of symptoms during stress moves the patient into the group where intervention is indicated.
In asymptomatic patients, intervention is indicated for severe AS with LVEF <50% without another cause. Early referral to the Heart Team should be considered with LVEF falling below 55%, very severe AS, rapid progression of Vmax by ≥0.3 m/s per year, significant valve calcification, BNP more than 3 times the age-sex norm, or systolic pulmonary artery pressure >60 mmHg at rest.
Choosing TAVI or Surgical Replacement
In 2025, the choice between TAVI and surgical aortic valve replacement has become even more anatomy- and risk-oriented. Considerations include age, expected life expectancy, surgical risk, concomitant valve lesions, aortic root anatomy, bicuspid valve, LVOT calcification, access routes, risk of conduction disturbances, and future coronary access possibilities. The decision should be made by the Heart Team, not just based on a single risk number.
Primary Mitral Regurgitation: Severity Thresholds
In primary mitral regurgitation, the cause lies in the leaflets or chordal apparatus: prolapse, flail segment, degeneration, endocarditis, rheumatic involvement. For the ultrasound protocol, critical factors include the Carpentier mechanism, affected segment, likelihood of durable repair, LV and LA sizes, pulmonary artery pressure, and presence of atrial fibrillation.
| Indicator | Threshold for Severe Primary MR | Comment |
|---|---|---|
| EROA | ≥40 mm² | Key quantitative criterion |
| Regurgitant volume | ≥60 ml | Confirms severe MR |
| Regurgitant fraction | ≥50% | Especially useful in comprehensive assessment |
| Vena contracta | ≥7 mm | Supports diagnosis of severe MR |
| LVEF | ≤60% | Threshold for LV dysfunction in severe MR |
| LVESD | ≥40 mm | Threshold for surgery in asymptomatic patients |
Indications for Intervention in Primary MR
Symptomatic severe primary MR is an indication for surgical treatment at acceptable risk; valve repair is preferred if a durable result is expected. In asymptomatic patients, surgery is indicated at LVEF ≤60% and/or LVESD ≥40 mm. These thresholds are crucial: in chronic MR, a 'normal' LVEF lower than expected may already indicate early LV decompensation.
If LVEF >60% and LVESD <40 mm, intervention is discussed with new episodes of atrial fibrillation caused by MR or systolic pulmonary artery pressure >50 mmHg at rest. An additional argument for early repair is significant enlargement of the left atrium: LAVI ≥60 ml/m² or LA diameter ≥55 mm in sinus rhythm, if the likelihood of successful and durable repair is high.
Secondary Mitral Regurgitation
In secondary MR, the valve is usually structurally preserved, and regurgitation arises due to LV or LA remodeling. Therefore, the first step is always optimal medical therapy for heart failure and resynchronization therapy if indicated. Only after this is the residual severity of MR and symptoms assessed.
For severe secondary MR, quantitative thresholds of EROA ≥30 mm² and regurgitant volume ≥45 ml are used, with mandatory integration of jet shape, LV size, pulmonary artery pressure, and quality of Doppler measurements. TEER is considered in symptomatic patients with severe secondary MR persisting despite optimal treatment if the anatomy is suitable and clinical benefit is expected. Surgery is more often discussed with the simultaneous need for CABG or other cardiac surgery.
Tricuspid Regurgitation: Don't Miss the Window
ESC/EACTS 2025 emphasizes that severe tricuspid regurgitation should not remain a 'late finding.' The protocol needs to include RV size and function, annular size, leaflet coaptation, hepatic veins, and pulmonary artery pressure. In severe TR, intervention should be discussed before irreversible RV dysfunction and severe systemic venous congestion. Transcatheter methods are becoming an option for high surgical risk patients with suitable anatomy.
Practical Algorithm for Echo Report
- Specify the mechanism of the defect, not just the degree: degenerative, functional, rheumatic, infectious, prosthetic.
- Provide quantitative severity parameters: for AS — Vmax, mean gradient, AVA, SVi; for MR — EROA, regurgitant volume, vena contracta, pulmonary pressure.
- Describe consequences: LVEF, LVESD, chamber volumes, LA, RV, pulmonary hypertension.
- Note triggers for referral to the Heart Team: symptoms, LVEF <50% in AS, LVEF ≤60% or LVESD ≥40 mm in primary MR, rapid Vmax increase ≥0.3 m/s/year, BNP >3 norms.
- If transcatheter treatment is planned, recommend 3D TEE and/or CT for anatomical planning.
Frequently asked questions
What is the main surgical threshold for asymptomatic primary mitral regurgitation?
In severe primary MR, surgery is indicated at LVEF ≤60% and/or LVESD ≥40 mm, even if there are no obvious symptoms.
When is low-gradient aortic stenosis considered severe?
Integration of AVA ≤1.0 cm² with flow assessment is needed. Low flow is defined as SVi ≤35 ml/m²; further considerations include LVEF, valve calcification, and confirmatory imaging methods.
Is a single EROA sufficient for deciding on TEER in secondary MR?
No. EROA ≥30 mm² supports severe secondary MR, but the decision on TEER is made after optimizing heart failure therapy and assessing symptoms, valve anatomy, LV size, and expected benefit.