Decision support only — not a substitute for the 2025 ESC/EACTS guideline or a Heart Valve Centre. The 2025 throughline is earlier intervention across aortic, mitral and tricuspid disease, with the Heart Team and multimodality imaging (3D echo, CT, CMR) central to timing and modality. Intervention decisions belong to a specialist valve service. Verify all doses and thresholds.
1 The five lesions — severe criteria & when to act
Aortic stenosisVmax ≥4 · MG ≥40 · AVA <1cm²
Severe AS; angina, syncope or exertional dyspnoea.
Symptomatic severe → intervene (I). Now also asymptomatic severe high-gradient → early intervention (IIa) EARLY TAVR. Modality: TAVI ≥70 / SAVR <70 (low risk).
Aortic regurgitationvolume overload
Severe AR.
Surgery if symptomatic, or asymptomatic with LVEF ≤55%, LVESDi >22 mm/m², or LVESVi >45 mL/m². TAVI may be considered if symptomatic, inoperable, suitable anatomy.
Mitral regurgitationprimary vs secondary
Distinguish degenerative (primary) from functional (secondary).
Primary → surgical repair (gold standard); now early repair in asymptomatic low-risk (I); TEER (IIa) if high-risk. Secondary → GDMT first, then TEER (I) if symptomatic + suitable COAPT.
Mitral stenosisusually rheumatic
Severe MS (valve area ≤1.5 cm²).
Percutaneous mitral commissurotomy if suitable anatomy & no LA thrombus/significant MR; otherwise surgery. Anticoagulate if AF (warfarin — not DOAC for rheumatic MS).
Tricuspid regurgitationunder-treated
Severe TR; distinguish atrial vs ventricular functional TR.
Repair at the time of left-sided valve surgery; transcatheter repair for selected severe symptomatic isolated TR TRILUMINATE. New BSA-indexed severity cut-offs.
The 2025 headline: act earlier. The TAVI age cut-off dropped from 75 to 70; asymptomatic severe AS and primary MR now have earlier-intervention recommendations; TEER is Class I for symptomatic secondary MR. All of it runs through the Heart Team — the recommendations set the threshold, the team sets the plan.
2 The aortic stenosis decision in detail
TAVI vs SAVR
- TAVI≥70 years, or high/prohibitive surgical risk, with suitable transfemoral anatomy.
- SAVR<70 with low surgical risk — lifetime-management/durability considerations; also for unsuitable TAVI anatomy or concomitant surgery.
- AnatomyAnnulus, access, coronary height, bicuspid valve — non-transfemoral TAVI if unsuitable for both surgery and TF access.
- Who decidesThe Heart Team, with the patient — not the gradient alone.
Confirming "severe" — discordance is common
- PivotSymptom onset (angina/syncope/exertional dyspnoea) transforms the prognosis — ask carefully.
- Low-flow LGLow-flow low-gradient AS → dobutamine stress echo (true vs pseudo-severe; contractile reserve).
- CT calciumAdjudicate borderline cases — sex-specific (>2000 AU men, >1200 AU women).
3 Prosthetic valves & anticoagulation
Mechanical vs bioprosthetic
- MechanicalDurable, but lifelong warfarin — favours younger patients who can manage a VKA.
- BioprostheticAvoids long-term anticoagulation but structural deterioration over time — older patients, anticoagulation contraindicated, or planned pregnancy.
- DecideAge, bleeding risk, pregnancy plans, and patient preference — a shared decision.
Anticoagulation rules
- MechanicalWarfarin only, INR target by valve type/position (≈2.5–3.5 mechanical mitral; ≈2.0–3.0 newer aortic). DOACs are contraindicated in mechanical valves.
- Bio/TAVIAntiplatelet ± short anticoagulation; a DOAC or warfarin only if there's another indication (e.g. AF).
- Rheumatic MSAF with rheumatic mitral stenosis → warfarin, not a DOAC.
4 The traps & the whole patient
Don't harm
- Severe ASSymptomatic severe AS carries high mortality — don't delay referral. Avoid vasodilators & aggressive diuresis (preload-dependent; can precipitate collapse).
- ExerciseAvoid strenuous exercise in symptomatic severe AS.
- Secondary MROptimise GDMT (± CRT) before intervening — much of it improves.
Don't miss
- EndocarditisProphylaxis for the highest-risk only (prosthetic valve/material, prior IE, certain CHD) before high-risk dental work; good dental hygiene matters more.
- SurveillanceAsymptomatic severe disease needs scheduled echo follow-up — intervals by lesion & severity.
- PregnancySevere AS/MS and mechanical-valve anticoagulation are high-risk — pre-pregnancy counselling and a pregnancy heart team.
Sources.
2025 ESC/EACTS Guidelines for the management of valvular heart disease (Eur Heart J 2025 — Heart Team & Heart Valve Centres; TAVI age cut-off 70; asymptomatic severe AS early intervention IIa; AR surgical thresholds; primary-MR early repair I & TEER IIa; secondary-MR TEER I; rheumatic-MS commissurotomy; transcatheter tricuspid; prosthetic-valve anticoagulation; multimodality imaging). eTG; CSANZ.
Key trials: EARLY TAVR / EVOLVED (asymptomatic severe AS); PARTNER & Evolut (TAVI across risk); COAPT (TEER in secondary MR); TRILUMINATE & TRI-FR (transcatheter tricuspid repair); RE-ALIGN (DOAC harm in mechanical valves).
Caveats: echo severity grading is operator- and flow-dependent — discordant AS needs multimodality adjudication before a high-stakes decision. Intervention timing and modality are Heart Team decisions at a valve centre; thresholds here are a guide, not an order set. TAVI access/funding pathways differ in Australia — confirm locally. Verify all doses, INR targets, and imaging cut-offs. Companion to the cardiac set (ACS, HFrEF, AF, hypertension, PH, myo/pericarditis).