Transcatheter Options for Severe AR Without Significant Calcification
TAVR is explicitly NOT recommended for severe native aortic regurgitation without calcification according to current guidelines, regardless of surgical risk, due to insufficient evidence to establish a favorable risk-benefit ratio. 1, 2
Guideline Position
The ACC/AATS/SCAI/STS expert consensus categorically excludes severe AR from TAVR indications because:
- TAVR devices were designed and validated exclusively for calcified, stenotic aortic valves where calcification provides structural anchoring support 2
- Severe AR presents fundamentally different anatomic challenges: lack of calcification for anchoring, dilated annulus, and requirement for complete seal rather than gradient reduction 2
- This exclusion applies to all surgical risk categories (prohibitive, high, intermediate, or low risk) 2
- The exclusion is based on absence of clinical trial data, not proven harm 1, 2
Current Standard of Care
For patients with severe symptomatic AR:
- Surgical aortic valve replacement remains the gold standard for acceptable surgical candidates 2
- For prohibitive surgical risk patients, medical management with afterload reduction is the current standard 2
- Enrollment in clinical trials investigating AR-specific transcatheter devices may be appropriate for prohibitive-risk patients 2
Off-Label TAVR Experience (Research Data Only)
While guidelines prohibit routine use, registry data on off-label TAVR for pure native AR shows:
Outcomes with Standard TAVR Devices
- Device success rates of only 72% in native AR (compared to >95% in stenosis) 3
- Early safety achieved in only 66% of patients 3
- Newer-generation devices show improved outcomes (85% device success vs 54% with older devices) primarily due to reduced paravalvular regurgitation (3% vs 27%) 3
Critical Predictors of Mortality
Independent predictors of 30-day mortality include: 3
- Body mass index <20 kg/m²
- STS score >8%
- Major vascular complications
- Moderate-to-severe residual AR
Technical Challenges
- High rates of valve embolization and migration with older-generation devices 3
- Significant paravalvular regurgitation (24-27% with older devices) 3
- Need for second valve implantation in 46% with older devices 3
Special Circumstance: Failing Bioprosthetic Valves
TAVR is a valuable option for severe AR in failing surgical bioprostheses (valve-in-valve procedure): 3
- Device success: 71%
- Early safety: 90%
- Clinical efficacy: 77%
- This represents a fundamentally different scenario with existing structural support from the surgical valve frame 3
Multidisciplinary Evaluation Required
Any consideration of transcatheter approaches for severe AR mandates Heart Team evaluation involving interventional cardiology, cardiac surgery, imaging specialists, and heart failure specialists 2, 4