Transcatheter Therapies for Aortic Regurgitation: Where Are We in 2023?

Abstract

Aortic regurgitation (AR) is retrograde flow across the aortic valve in diastole and is classified from stage A to D based on severity and symptoms. Severe symptomatic AR (stage D) is a class I indication for surgical aortic valve replacement per the 2020 American College of Cardiology/American Heart Association guidelines. Though off-label, patients with prohibitive surgical risk may benefit from transcatheter aortic valve replacement (TAVR) in appropriately selected patients. However, TAVR is challenging in AR due to a lack of leaflet and annular calcification and dilation of the perivalvular apparatus, compromising the optimal anchorage of the bioprosthesis with a risk of prosthetic valve leak and embolization. Valve oversizing by 10–15% is frequently required, with caution not to oversize beyond 20%. Multimodality imaging, including echocardiography, magnetic resonance imaging, and computerized tomography, is essential for procedural planning. Registry data shows acceptable results for off-label TAVR with newer generation valves such as Medtronic Evolut and Edwards Sapien 3 for native AR. The JenaValve designed especially for TAVR for native AR is currently undergoing clinical trial. Until the results of randomized clinical trials are available, careful selection of native AR patients for TAVR is paramount to procedural and clinical success.