The 2025 Annual Congress of the European Society of Cardiology (ESC) and World Congress of Cardiology kicked off in Madrid, Spain, from August 29 to September 1. The release of landmark guidelines has always been one of the key highlights of the ESC. This year, the Guidelines for the Management of Valvular Heart Disease were the first to be released, attracting attention from around the world. Over the past 20 years, cardiac valvular heart disease, especially interventional therapy for valvular heart disease, has developed rapidly and become a hot topic in cardiovascular medicine. Since the last ESC Valvular Heart Disease Guidelines published in 2021, significant progress has been made in the treatment of valvular heart disease. Therefore, the updated content of this year's valvular guidelines is very rich. This article summarizes and interprets the top ten key points:

1. TAVR Indication Age Lowered; Bicuspid Aortic Valve and Aortic Regurgitation Included as Indications for the First Time

The new guidelines adjust the recommended age for patients undergoing Transcatheter Aortic Valve Replacement (TAVR) from 75 years (2021 version) to 70 years. It is recommended that patients aged ≥70 years with severe tricuspid aortic stenosis and suitable anatomical structure undergo TAVR treatment (Class I, Level A indication). At the same time, bicuspid aortic valve and aortic regurgitation are explicitly recommended as indications for the first time. The guidelines suggest that for patients at high risk of surgical operation, if the anatomical structure is suitable, TAVR may be considered for the treatment of severe bicuspid aortic stenosis (Class IIb, Level B). For symptomatic patients with severe aortic regurgitation who are evaluated by the heart team as unsuitable for surgery, if the anatomical structure is appropriate, TAVR may be considered for treatment (Class IIb, Level B). Patients with bicuspid aortic stenosis and isolated aortic regurgitation are common in China, and China leads the world in device research and development and clinical experience in this field. The *Chinese Expert Consensus on TAVR (2020)*, led by us, has long made recommendations similar to those in this guideline regarding TAVR indications for elderly patients and those with bicuspid aortic valve, defining age over 70 years as an absolute indication for TAVR, and classifying bicuspid aortic valve and isolated aortic regurgitation in patients at high surgical risk as relative indications for TAVR. The *Chinese Expert Consensus on Transfemoral TAVR for Isolated Aortic Regurgitation (2023)*, also led by us, puts forward similar recommendations on TAVR indications, and further elaborates on and recommends the clinical and anatomical indications, surgical strategies and techniques, as well as complication management of TAVR in the treatment of aortic regurgitation.

2. Mixed Aortic Valve Disease Granted Surgical Indications

The new guidelines provide clear recommendations for intervention in patients with concurrent aortic stenosis and regurgitation. It is recommended that symptomatic patients with moderate mixed aortic stenosis and moderate regurgitation, with a mean transvalvular pressure gradient ≥40 mmHg or a peak velocity (Vmax) ≥4.0 m/s, undergo intervention (Class I, Level B). For asymptomatic patients with moderate mixed aortic stenosis and moderate regurgitation, Vmax ≥4.0 m/s, and left ventricular ejection fraction (LVEF) <50% not caused by other heart diseases, intervention is recommended (Class I, Level C). Clinically, some patients have moderate aortic regurgitation combined with moderate stenosis. From a pathophysiological perspective, these patients also have severe hemodynamic impairment. Based on the latest research results, this guideline classifies such patients as candidates for surgical intervention.

3. Adjustments to Indications for Concurrent PCI During TAVI

The new guidelines propose that for patients being considered for TAVR, if the image quality of preoperative cardiac computed tomography (CT) is sufficiently high to rule out significant coronary artery disease, coronary angiography during the operation may be omitted (Class IIa). This practice is already widely adopted in most clinical settings in China. For patients with TAVR as the main indication, if they have coronary artery stenosis ≥90% in vessels with a reference diameter ≥2.5 mm, percutaneous coronary intervention (PCI) should be considered (Class IIa, Level B), mainly based on the results of the NOTION-3 study. For all patients with transcatheter valve intervention (including TAVR) as the main indication, PCI may be considered for those with proximal stenosis ≥70% in major coronary arteries. However, the recommendation level has been downgraded from Class IIa (2021 version) to Class IIb, mainly because there is insufficient high-quality evidence to support this, and even some clinical studies have shown that overly aggressive PCI does not benefit patients with TAVR combined with coronary artery disease.

4. Upgraded TEER Indications: FMR to Class I, DMR to Class IIa, and AFMR Added as Class IIb

In terms of interventional therapy for mitral regurgitation, this ESC guideline features a major upgrade in recommendations for Transcatheter Edge-to-Edge Repair (TEER) indications. Previous large-scale randomized controlled trials (RCTs) such as the COAPT study and RESHAPE-HF-2 study have confirmed that TEER is safe and effective in the treatment of severe secondary mitral regurgitation (Functional Mitral Regurgitation, FMR). For symptomatic severe ventricular secondary mitral regurgitation, this ESC guideline upgrades TEER to a Class I recommendation.

For severe primary mitral regurgitation (Degenerative Mitral Regurgitation, DMR) in patients at high surgical risk with suitable anatomy, the indication for TEER in the 2021 version was Class IIb, and this guideline updates it to a Class IIa indication. High-risk and elderly patients with chronic DMR may benefit from the less invasive TEER procedure. The use of the latest generation of TEER devices and the accumulated experience of medical teams have improved patient outcomes and enabled the successful treatment of patients with more complex anatomical conditions. For...

5. TMVI Recommended for Patients with Mitral Annular Calcification (MAC) for the First Time (Class IIb Recommendation)

Transcatheter Mitral Valve Implantation (TMVI) or Transcatheter Mitral Valve Replacement (TMVR) has long been a hot research direction. Although the development process has been challenging and it is not yet fully mature, TMVI is relatively mature in the treatment of mitral annular calcification (MAC) and has been recommended in guidelines for the first time. Not long ago, the U.S. Food and Drug Administration (FDA) also approved Tendye for TMVI treatment of MAC for the first time, bringing TMVI into the stage of clinical promotion and application. Mitral annular calcification (MAC) is an indicator of the severity of cardiovascular disease and is associated with an increased risk of atrial fibrillation, stroke, and death. Most patients with MAC do not have significant valvular dysfunction, but some patients may develop mitral stenosis or regurgitation. Usually, mitral stenosis (MS) caused by MAC occurs when calcification extends to the mitral valve leaflets or subvalvular anatomy, and is associated with mixed mitral regurgitation (MR) in some patients. These patients face high surgical risks, as the calcified annulus makes valve replacement or repair difficult, and TMVI provides a good solution. TAVI valves (balloon-expandable valves) and specially developed valves can be used for TMVI procedures.

Atrial Functional Mitral Regurgitation (AFMR) in patients who remain symptomatic after drug treatment has been listed as a TEER indication for the first time (Class IIb recommendation), while surgical treatment is recommended as a Class IIa indication for such patients.

6. Tricuspid Interventional Therapy Indication Upgraded from Class IIb to Class IIa

In the 2021 guidelines, tricuspid interventional therapy could be explored in experienced centers for patients with tricuspid regurgitation at high surgical risk, with a recommendation level of Class IIb. This guideline upgrades it to Class IIa. Interventional therapy for tricuspid regurgitation mainly includes transcatheter edge-to-edge repair (TEER), direct annuloplasty, and in-situ and ectopic tricuspid valve replacement. The landmark TRILLUMINATE study showed that compared with drug treatment, tricuspid TEER can reduce the incidence of the composite endpoint of all-cause death, tricuspid surgery, or heart failure hospitalization, and can improve patients' quality of life. Another RCT (TRISCEND II trial) compared the efficacy of transcatheter tricuspid valve replacement (using the EVOQUE valve) with optimized drug treatment in symptomatic patients with severe tricuspid regurgitation (TR), showing similar results. The win ratio was in favor of transcatheter tricuspid valve replacement, mainly due to improvements in symptoms and quality of life. Reverse remodeling of the right ventricle was also observed in these studies. The guidelines also propose that transcatheter treatment should be considered for high-risk patients with symptomatic severe TR who still have symptoms despite optimized drug treatment and have no severe right ventricular dysfunction or pre-capillary pulmonary hypertension, to improve quality of life and right ventricular remodeling. The *Chinese Expert Consensus on Transcatheter Tricuspid Interventional Therapy (2024)*, led by us, also recommends detailed indications for tricuspid interventional therapy and its comprehensive management.

7. Recommendations for Transcatheter Valve-in-Valve Implantation for Mitral and Tricuspid Valves Upgraded (from Class IIb to Class IIa)

Transcatheter valve-in-valve implantation for mitral or tricuspid valves is recommended for patients with prosthetic valve degeneration at moderate to high surgical risk and suitable anatomical conditions. The indication level has been upgraded from Class IIb (2021 version) to Class IIa, which is attributed to the increasing number of clinical studies and experience in this field. At the same time, TAVR is also listed as a Class IIa indication for patients with aortic valve degeneration at moderate surgical risk. Prosthetic valve dysfunction may result from inherent permanent changes in the prosthetic valve itself (defined as structural valve deterioration, SVD) or non-structural valve dysfunction (caused by any abnormality other than the prosthetic valve itself). Patients with prosthetic valve degeneration and moderate to severe hemodynamic changes should be immediately referred to an experienced cardiac valve center for evaluation and treatment, and all causes of non-structural valve dysfunction should be ruled out. The choice of treatment method (reoperation or transcatheter valve-in-valve implantation) should be determined by discussion among an interdisciplinary heart team, depending on the reoperation risk and anatomical considerations, including the risk of coronary artery obstruction, as well as the type and size of the prosthesis. Given the large size of biological valves for mitral or tricuspid valves, transfemoral/transseptal valve-in-valve implantation is an effective alternative to reoperative open-heart surgery. During mitral valve-in-valve implantation, although the risk of left ventricular outflow tract obstruction is rare, it should be carefully ruled out, especially in patients with small and hypertrophic ventricles.

8. Aortic Valve Repair Upgraded from Class IIb to Class IIa; Minimally Invasive Mitral Valve Repair Recommended (Class IIb)

For certain types of patients with severe aortic regurgitation (AR), aortic valve repair instead of aortic valve replacement is recommended in experienced centers, with the recommendation strength upgraded from Class IIb (2021 version) to Class IIa. This is because aortic valve repair avoids the drawbacks of anticoagulation for mechanical valves and degeneration of biological valves, and more and more evidence has confirmed its durability, making it an important direction in the development of surgical procedures. In most cases of AR, aortic valve replacement remains the standard surgical method. However, due to a better understanding of the pathophysiology of the aortic root and favorable long-term outcomes, valve-sparing aortic root replacement and aortic valve repair are increasingly performed in experienced cardiac centers. In patients with an enlarged aortic root and good tissue quality (i.e., flexible leaflets with normal mobility), studies have shown that valve-sparing procedures (such as the Bentall procedure) are superior in terms of long-term mortality and overall morbidity. Therefore, such procedures should be given priority in experienced centers, especially for patients with bicuspid aortic valve (BAV), for whom valve-sparing or repair procedures should be considered.

To reduce the length of hospital stay for mitral valve surgery and accelerate patients' postoperative recovery, minimally invasive surgical mitral valve repair is recommended for the first time (Class IIb recommendation). For severe DMR, restoring the anatomical structure through surgical mitral valve repair (including annuloplasty) is the preferred treatment for patients. When mitral valve repair is not feasible, surgical mitral valve replacement with preservation of subvalvular structures should be performed. Minimally invasive mitral valve repair through a small right thoracic incision is increasingly used in experienced centers. A recent RCT study confirmed that it has similar safety and efficacy compared with conventional sternotomy. Minimally invasive mitral valve repair is associated with a shorter hospital stay and improved physical activity within the first 6 weeks after surgery, but this difference disappears at 12 weeks. Therefore, in experienced centers, minimally invasive mitral valve repair may be considered to shorten the hospital stay and accelerate recovery.

9. Recommendations for Concurrent Atrial Fibrillation Left Atrial Appendage Closure or Atrial Fibrillation Ablation During Valvular Surgery Upgraded (from Class IIa to Class I)

For patients undergoing valvular surgery with concurrent atrial fibrillation, the recommendation for concurrent surgical atrial fibrillation ablation and surgical left atrial appendage excision has been upgraded from Class IIa to Class I. The interaction between atrial fibrillation and valvular heart disease (VHD) is complex and plays a crucial role in patients' prognosis and the progression of VHD. VHD is independently associated with atrial fibrillation, and nearly one-third of patients with atrial fibrillation have a history of VHD. Conversely, atrial fibrillation is a major predisposing factor for atrial secondary mitral regurgitation (MR) and tricuspid regurgitation (TR). Patients with both VHD and atrial fibrillation face a high risk of thromboembolic or bleeding complications. In the Left Atrial Appendage Occlusion Study (LAAOS) III trial, for patients with atrial fibrillation and a CHADS-VASc score ≥2 who underwent cardiac surgery, left atrial appendage closure during surgery was associated with a 33% reduction in the risk of stroke or systemic embolism during a mean follow-up of 3.8 years. In recent years, clinical evidence supporting better outcomes with concurrent ablation during valvular surgery has gradually increased.

10. Antithrombotic Therapy Regimens Tend to Be Simplified

Antithrombotic therapy has always been an important part of valvular guidelines. Overall, the recommendations for antithrombotic therapy in this guideline tend to simplify the regimens. Based on the increasing clinical evidence on antithrombotic therapy after TAVR in recent years, the new guideline clearly states for the first time that dual antiplatelet therapy should not be recommended for preventing thrombosis after TAVR unless there are clear indications (Class III, Level B). For patients without indications for oral anticoagulants (OAC), low-dose aspirin (75-100 mg/day) is recommended for 12 months after TAVR (Class I, Level A); after 12 months, long-term treatment with low-dose aspirin (75-100 mg/day) should be considered (Class IIa, Level C). For TAVR patients with other indications for OAC, OAC is recommended (Class I, Level B); for patients without baseline indications, routine use of OAC after TAVR is not recommended (Class III, Level A).

For patients with newly implanted aortic mechanical valves who undergo major non-cardiac surgery or invasive procedures, it is recommended to interrupt vitamin K antagonists (VKA) 3-4 days before surgery and resume them after surgery, without the need for low-molecular-weight heparin bridging. This is considered to reduce bleeding in such patients (Class I indication). Within 3 months after surgical implantation of an aortic or mitral biological valve, VKA (Class I) or non-vitamin K antagonist oral anticoagulants (NOAC) (Class IIb) can be used; after 3 months, lifelong low-dose aspirin (ASA) (75-100 mg/day) may be considered (Class IIb recommendation). For surgical mitral and tricuspid valve repair, 3 months of anticoagulation (VKA or NOAC) is recommended postoperatively (Class IIa), but antiplatelet therapy alone is sufficient for patients at high risk of bleeding (Class IIb).

Acknowledgements: Thanks to Doctors Hong Nanchao and Chen Shasha for their participation in writing this article.