Transcatheter Aortic Valve Implantation for Pure Aortic Regurgitation

Abstract

Transcatheter aortic valve implantation (TAVI) has transformed the management of severe aortic stenosis (AS), evolving from a therapy reserved for inoperable patients to a viable treatment across the spectrum of surgical risk. This success has stimulated innovation in transcatheter therapies for other valvular heart diseases, including aortic regurgitation (AR). In contrast to AS, AR is characterised by heterogeneous aetiologies, absence of annular calcification, larger and more elliptical annular dimensions, and concomitant aortopathy. These challenges have limited the efficacy and safety of conventional transcatheter aortic valves (TAVs), use of which in pure native AR is associated with high rates of valve embolisation, significant residual regurgitation, permanent pacemaker implantation, and mortality. The development of dedicated TAVs designed specifically for the treatment of AR has addressed many of these anatomical challenges. The JenaValve Trilogy and J-Valve systems incorporate leaflet-grasping mechanisms that enable secure anchoring independent of calcification, resulting in transformation of procedural and clinical outcomes. Recent prospective registry data, including the landmark ALIGN-AR trial, demonstrate high technical and procedural success rates, low residual regurgitation, acceptable safety profiles, and meaningful improvements in functional status and ventricular remodelling. These data have informed contemporary guideline updates, with the 2025 European Society of Cardiology (ESC)/European Association of Cardiothoracic Surgery (EACTS) Guidelines for the management of valvular heart disease issuing the first conditional recommendation for TAVI in selected patients with severe AR and the National Institute for Health and Care Excellence (NICE) recommending TAVI for native AR in patients for whom surgical AVR is not available or is high risk. This review summarises the clinical implications of AR, examines current guideline recommendations for management, and critically appraises the evidence supporting transcatheter treatment strategies.