The publication of new clinical practice guidelines usually generates headlines around their most visible changes. In the case of the 2025 ESC/EACTS guidelines on valvular heart disease, much of the debate has focused on the age threshold for choosing between surgical aortic valve replacement and TAVI. However, reducing the document to this discussion would mean overlooking a substantial part of its message.

The article by Marín-Cuartas, de Waha, and Borger provides a specifically surgical interpretation of these guidelines. It is not intended to replace the complete document, but rather to select the recommendations with the greatest impact on contemporary cardiac surgery. This is precisely where its value lies: it reminds us that, despite the continuing expansion of transcatheter therapies, the new guidelines do not displace surgery. Instead, they more clearly redefine its role within a more structured, multidisciplinary, and lifetime-oriented approach to valvular heart disease.

The article under discussion is a brief review published in surgeons’ notebook format that examines the most relevant surgical implications of the 2025 ESC/EACTS guidelines for the management of VHD. The authors summarize 10 key messages: the structural definition of Heart Valve Centres; the stronger emphasis on AV repair and valve-sparing root procedures; the formal incorporation of lifetime management into the treatment of AS; the role of surgery in asymptomatic primary MR; the first specific recommendation for minimally invasive mitral valve surgery; the distinction between atrial and ventricular secondary MR; a more preventive approach to secondary TR; new guidance for mixed moderate aortic valve disease; the integration of surgical AF treatment into valve surgery; and the use of CCTA as a screening tool in selected patients. The overall message is that the guidelines consolidate a model of valve surgery based on expertise, outcomes, anatomical selection, and long-term planning.

The authors conclude that the 2025 ESC/EACTS guidelines clearly reinforce the role of cardiac surgery within a structured model of valve care centred on quality, Heart Team decision-making, and lifetime planning. In their interpretation, the document does more than update specific indications: it confirms that surgery remains an essential component of modern VHD treatment.

COMMENTARY:

The main strength of the article is that it shifts attention away from the most widely publicized question—“TAVI or surgery?”—towards a more important issue: how should contemporary valve care be organized to ensure that the right decisions are made from the first intervention onwards? This distinction is far from trivial. In daily practice, particularly in younger patients or those with complex anatomy, the problem does not end once a valve has been implanted. Instead, it may initiate a sequence involving repeat interventions, prosthetic valve deterioration, difficulties with future coronary access, the risk of prosthesis–patient mismatch, the need for anticoagulation, patient preferences, and the actual availability of technical expertise.

For this reason, lifetime management is probably one of the most relevant concepts introduced by the new guidelines. In AS, age remains a useful practical variable, but it can no longer be interpreted in isolation. In patients younger than 70 years who are at low surgical risk, SAVR retains a preferential role. In patients aged 70 years or older with a tricuspid AV, favourable anatomy, and transfemoral access, TAVI is consolidated as the preferred option. Between these two extremes, however, lies the real territory of the Heart Team: bicuspid AV, aortopathy, a small annulus, CAD, the risk of future coronary obstruction, the feasibility of TAV-in-SAV or TAV-in-TAV, frailty, life expectancy, and informed patient preferences.

This approach is particularly important in bicuspid AV disease. The guidelines remind us that surgery remains the standard treatment in younger patients, especially when aortopathy or anatomy unfavourable for TAVI is present. In practice, this prevents age from becoming an automatic decision rule. A technically feasible TAVI is not always the best initial strategy if it adversely affects future treatment options. This is an idea that surgeons must communicate clearly: surgery should not be compared only with the immediate results of TAVI. It may provide a more comprehensive solution when the valve, aortic root, ascending aorta, small annulus, or associated CAD must also be addressed.

Another strength of the article is that it recovers a modern concept of valve surgery. The guidelines are not limited to valve replacement; they also emphasize preservation, repair, and combined procedures. AV repair and valve-sparing root surgery gain importance in selected patients with AR, good tissue quality, and treatment at experienced centres. The same applies to mitral valve repair, which now receives a particularly strong recommendation in severe primary MR, including asymptomatic patients when several risk markers are present, such as AF, pulmonary hypertension, left atrial enlargement, or secondary TR.

This change has a practical implication: it is becoming increasingly difficult to justify waiting until patients with VHD present with advanced ventricular damage, established pulmonary hypertension, permanent AF, or right ventricular dysfunction. The guidelines encourage earlier intervention in specific settings, but not indiscriminate intervention. Appropriate implementation requires structured follow-up, high-quality imaging, reproducible measurements, exercise testing when indicated, biomarkers in selected cases, and genuine multidisciplinary discussion of each patient. The danger of more proactive recommendations is that they may be applied as rigid formulas; their real value lies in identifying patients who are beginning to lose cardiac reserve before irreversible damage develops.

TR is another clear example. For years, the tricuspid valve was considered the forgotten valve and was frequently treated too late—or not treated at all—during left-sided valve surgery. The new guidelines support a more preventive strategy: concomitant tricuspid valve repair should be performed when at least moderate TR is present and may be considered even in mild TR when annular dilation is identified. For the surgeon, this has a direct implication: during mitral or aortic valve surgery, it is no longer sufficient to label TR as “functional” and disregard it. The annulus should be measured, right ventricular function assessed, the risk of progression estimated, and the opportunity for concomitant treatment considered to avoid a high-risk reoperation years later.

The integration of surgical AF treatment is also highly relevant. Left atrial appendage occlusion in patients with a history of AF undergoing valve surgery, together with concomitant ablation—particularly during mitral valve surgery—should no longer be regarded as an optional adjunct. Instead, these procedures form part of a comprehensive valve strategy. This fits naturally with the new distinction between atrial and ventricular secondary MR. Atrial secondary MR, associated with atrial enlargement, AF, and frequently TR, may benefit from a surgical intervention that simultaneously addresses the mitral annulus, the tricuspid valve, the arrhythmia, and the left atrial appendage. This remains an area in which surgery has a conceptual advantage: several mechanisms of the disease can be treated during a single procedure.

The article also highlights an organizational issue that may appear less striking but is potentially more transformative: the definition of a Heart Valve Centre. The guidelines specify that these centres should provide 24/7 cardiac surgery and interventional cardiology, advanced imaging, regular Heart Team meetings, sufficient procedural volume, outcome auditing, training, and specialized follow-up. This has an uncomfortable but necessary implication: not every procedure should be performed at every institution. Local expertise and actual outcomes matter. Complex mitral valve repair, valve-sparing root surgery, AV repair, minimally invasive procedures, TAVI in complex anatomies, tricuspid interventions, and high-risk valve-in-valve procedures require the concentration of experience.

The article is inevitably selective. It summarizes the most important surgical messages but does not examine in depth the evidence underlying each recommendation or the remaining areas of uncertainty. It also provides only limited discussion of the potential conflicts between accessibility, centralization, waiting lists, and geographical equity. This issue is important: recommending high-volume centres is reasonable, but it must be accompanied by well-designed referral networks so that patients are neither treated too late nor lost within bureaucratic pathways. Furthermore, many recommendations remain supported by limited evidence, registries, observational analyses, or expert consensus, particularly in AV repair, TR, atrial secondary MR, and lifetime treatment strategies.

Nevertheless, the overall interpretation is positive. The 2025 ESC/EACTS guidelines appear to acknowledge a reality already familiar in clinical practice: contemporary valve treatment cannot be determined solely by surgical risk or age. Decisions must integrate anatomy, life expectancy, durability, comorbidities, accumulated cardiac damage, institutional quality, and patient preferences. In this setting, cardiac surgery does not lose prominence; its role changes. Surgery is no longer simply the invasive alternative to transcatheter treatment, but an anatomical, reparative, and strategic tool within a long-term management plan.

Perhaps the most useful message for daily practice is the following: the first valve intervention should be selected with the second intervention in mind, even when that second procedure may never become necessary. This way of reasoning requires surgeons, interventional cardiologists, imaging specialists, clinical cardiologists, and patients to speak the same language. The article by Marín-Cuartas et al. has the merit of reminding us that, beyond the TAVI–SAVR debate, the 2025 guidelines propose something more ambitious: a less episodic and more carefully planned model of valve care.

REFERENCE:

Marín-Cuartas M, de Waha S, Borger MA. Surgical implications of the 2025 ESC/EACTS guidelines for the management of valvular heart disease: key recommendations bridging guidelines and clinical practice. European Journal of Cardio-Thoracic Surgery. 2026;68(5):ezag158. doi:10.1093/ejcts/ezag158.