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enhance comprehension of recommendations after publication, and to reinforce transparency in the guidelines development process. The tables are published in their own section of the guidelines and reference specific recommendation tables. After an iterative process of deliberations, a first Task Force vote on all recommendations is conducted prior to the initiation of rounds of review. A second Task Force vote on all recommendations is conducted after the final round of review and revision. For each vote, the Task Force follows ESC voting procedures and all recommendations require at least 75% agreement among voting members to be approved. Voting restrictions may be applied based on declarations of interests. The writing and reviewing panels provide declaration-of-interest forms for all relationships that might be perceived as real or potential sources of conflicts of interest. Their declarations of interest are reviewed according to the ESC declaration-of-interest rules, which can be found on the ESC website (http://www.escardio.org/doi) and are compiled in a report published in a supplementary document with the guidelines. Funding for the development of these ESC/EACTS Guidelines was derived entirely from the ESC and the EACTS with no involvement of the healthcare industry. The ESC CPG Committee supervises and co-ordinates the preparation of new guidelines and approves their publication. In addition to review by the ESC CPG Committee, these ESC/EACTS Guidelines underwent multiple rounds of double-blind peer review on a dedicated online review platform. The review was conducted by topic experts, including members from ESC National Cardiac Societies, EACTS Network of National Cardiac Surgery Societies and from relevant ESC Subspecialty Communities. The Guideline Task Force considered all review comments and was required to respond to all those classified as major. After appropriate revisions, the Task Force, the ESC CPG Committee members and the EACTS Council members approved the final document for publication in the European Heart Journal and in the European Journal of Cardio-Thoracic Surgery. Unless otherwise stated, the guideline content refers to sex, understood as the biological condition of being male or female, defined by genes, hormones, and sexual organs. Off-label use of medication may be presented in this guideline if a sufficient level of evidence shows that it can be considered medically appropriate for a given condition. However, decisions on off-label use must be made by the responsible health professional giving special consideration to ethical rules concerning healthcare, the specific situation of the patient, patient consent, and country-specific health regulations.

2 Introduction

New evidence has accumulated since the publication of the 2021 European Society of Cardiology (ESC)/European Association for Cardio-Thoracic Surgery (EACTS) Guidelines for the management of valvular heart disease, leading to the need for new recommendations (Table 3 New recommendations) and revision of existing recommendations (Table 4 Revised recommendations) concerning the following topics: • The importance of shared and patient-centred decision-making by multidisciplinary expert Heart Teams working within a regional network has been reinforced. Patients with complex conditions or requiring complex procedures should be referred to high-volume centres, where corresponding expertise is concentrated to ensure high-quality treatment. • Advanced imaging modalities—such as three-dimensional (3D) echocardiography, cardiac computed tomography (CCT), and cardiac magnetic resonance (CMR) imaging—have gained importance and become a central aspect in the screening and evaluation of patients with valvular heart disease (VHD). • Emphasis is put on the importance of correctly assessing the cause(s) and mechanism(s) of all valve diseases. In particular, the distinction between atrial and ventricular secondary mitral regurgitation (SMR) has clear implications in terms of prognosis and management. • New evidence has been published regarding the benefits of intervention for the treatment of severe aortic stenosis (AS) irrespective of symptoms, left ventricular ejection fraction (LVEF), and flow reserve. • The criteria used for decision-making concerning the optimal modality of AS treatment [transcatheter aortic valve (AV) implantation (TAVI) or surgical AV replacement (SAVR)] based on a Heart Team approach have been refined, including the combination of key aspects such as age, procedural risk, and anatomical suitability, incorporating estimated life expectancy and lifetime management considerations. • Further randomized evidence confirming the mid-term safety and efficacy of TAVI in low-risk patients has been published. • The indications for TAVI in patients with bicuspid AV (BAV) stenosis or severe aortic regurgitation (AR) at high surgical risk, based on anatomical suitability and a comprehensive Heart Team evaluation, are discussed. • Several advancements have been made regarding the treatment of patients with primary mitral regurgitation (PMR): refinement of the criteria for intervention in asymptomatic patients; demonstration of the value of minimally invasive mitral valve (MV) surgery to reduce the length of hospital stay and accelerate recovery; and large-scale data confirming the role of transcatheter edge-to-edge repair (TEER) in high-risk patients. • Longer-term follow-up data and two new randomized controlled trials (RCTs) concerning the management of patients with ventricular SMR have been published. • The evidence for the treatment of tricuspid valve (TV) disease is growing—including new randomized data supporting concomitant TV repair during left-sided valve surgery, and transcatheter options (repair and replacement) that reduce tricuspid regurgitation (TR), promote reverse right ventricular (RV) remodelling, and improve quality of life compared with medical treatment. • Efforts have been made to provide improved guidance regarding the diagnostic steps and management of patients with multiple and mixed VHD. • Definitions of structural valve deterioration (SVD) have been updated and unified. • The recommendations concerning the use of direct oral anticoagulants (DOACs) in patients with VHD have been updated, and the importance of education and (self-)monitoring is emphasized. • Sex-specific considerations in patients with VHD have been extended and regrouped into a new dedicated section (see Section 17).

Because of demographic changes, patients with VHD frequently present with concomitant cardiovascular diseases, increasing the complexity of treatment strategies. These Guidelines focus on acquired Downloaded from academic.oup.com/eurheartj/article/46/44/4635/8234488 by guest on 07 October 2026