Transcatheter Aortic Valve Implantation for Pure Native Aortic Regurgitation: A Comprehensive State-of-the-Art Review

Pure native aortic regurgitation (AR) remains a challenging and frequently undertreated valvular disease, associated with substantial morbidity and mortality. Surgical aortic valve repair or replacement remains the standard of care; however, many patients are older, frail, or at prohibitive surgical risk, creating an unmet need for less invasive therapeutic options. In this context, transcatheter aortic valve implantation (TAVI) has progressively emerged as a potential alternative. However, the application of TAVI in AR has historically been limited by the absence of annular and leaflet calcification, the presence of large and often noncircular annuli, and the resulting risks of transcatheter valve embolization or migration, residual paravalvular regurgitation, and conduction disturbances. This review summarizes contemporary evidence on TAVI for pure native AR, spanning early off-label experience with first-generation self-expanding and balloon-expandable valves to newer-generation platforms and dedicated devices. Recent observational studies and multicenter registries have shown meaningful improvements in procedural success, lower rates of residual AR and second valve implantation, and acceptable short- and mid-term mortality with contemporary off-label devices. Dedicated systems, including JenaValve Trilogy, J-Valve, and others, have further enhanced anchoring and sealing performance, achieving markedly lower rates of valve migration and significant residual regurgitation. Nonetheless, permanent pacemaker implantation remains a major limitation for several platforms. In parallel, the AURORA trial introduced an anatomy-guided strategy based on multidetector computed tomography classification and dual anchoring theory, suggesting that careful anatomical selection and optimized implantation planning may improve outcomes even with non-dedicated devices. Overall, TAVI has become a viable option for selected high-risk patients with severe symptomatic pure native AR and has now been incorporated into contemporary guidelines in this setting. Future progress will likely depend on further refinement of dedicated devices, reduction of conduction-related complications, and broader integration of patient-specific anatomical and biomechanical assessment to optimize device selection and implantation strategy.