Contemporary Diagnosis and Treatment of Aortic Regurgitation: A State-of-the-Art Review (JACC February 2026-1)-Article: Contemporary Diagnosis and Treatment of Aortic Regurgitation: A State-of-the-Art Review

Article: Contemporary Diagnosis and Treatment of Aortic Regurgitation: A State-of-the-Art Review

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This state-of-the-art review comprehensively addresses contemporary diagnosis and treatment of native aortic regurgitation (AR), a prevalent and often under-recognized valvular heart disease leading to adverse left ventricular remodeling and heart failure if untreated. AR's heterogeneous etiology includes congenital malformations, connective tissue disorders, degenerative disease, and inflammatory or iatrogenic causes. Advances in multimodal imaging—particularly transthoracic echocardiography, cardiac magnetic resonance (CMR), and computed tomography (CT)—have refined assessment of regurgitant severity, left ventricular volumetrics, myocardial strain, and fibrosis, enabling earlier disease detection and more precise timing of intervention. Novel echocardiographic techniques such as speckle-tracking strain and emerging artificial intelligence applications enhance risk stratification beyond traditional left ventricular ejection fraction (LVEF) and dimension thresholds.<br /><br />Current guidelines recommend surgical aortic valve replacement (SAVR) as the gold standard treatment for symptomatic severe AR and for asymptomatic patients showing signs of ventricular dysfunction or remodeling. Surgical options have evolved beyond prosthetic replacement to include valve-sparing root replacement, native valve repair, and the Ross procedure, especially beneficial in younger patients and expert centers. Prosthetic choices balance durability and anticoagulation needs: mechanical valves offer lifelong durability but require warfarin, while bioprostheses allow valve-in-valve transcatheter options but have limited longevity.<br /><br />Transcatheter aortic valve replacement (TAVR), established for aortic stenosis, faces anatomic challenges in AR due to lack of annular calcification, large and elliptical annuli, and compliant roots causing difficulties in valve anchoring and risks of paravalvular leak and device migration. Earlier off-label use of TAVR devices designed for stenosis showed suboptimal outcomes. Dedicated transcatheter devices tailored for AR, notably the JenaValve Trilogy and J-Valve systems, employ novel leaflet-engaging anchoring mechanisms circumventing these limitations. Early multicenter studies demonstrate high procedural success, low residual AR, and promising short- and mid-term outcomes, with CE mark approval in Europe and pending U.S. FDA authorization. These devices expand treatment options for inoperable or high-risk patients ineligible for surgery.<br /><br />Future directions emphasize reducing pacemaker rates associated with TAVR in AR, refining patient-specific intervention timing via advanced imaging and machine learning models, and ongoing randomized trials to compare surgical and transcatheter therapies. Multidisciplinary, anatomy-specific approaches integrating imaging, biomarkers, and evolving technologies will optimize individualized management and address the significant under-treatment gap, particularly in elderly and frail populations. Surgical innovations alongside dedicated transcatheter systems herald a new treatment paradigm for AR, aiming to improve outcomes and broaden care access for this historically underserved patient group.

Keywords

aortic regurgitation

valvular heart disease

left ventricular remodeling

multimodal imaging

echocardiography

cardiac magnetic resonance

transcatheter aortic valve replacement

surgical aortic valve replacement

JenaValve Trilogy

machine learning in cardiology