Background: Transcatheter aortic valve replacement (TAVR) is still not used regularly in pure aortic regurgitation. Due to its rapid development, more research on current data is crucial.
Methods: Using German national records, all isolated surgical aortic valve replacements (SAVR) or TAVR for pure aortic regurgitation in 2018-2020 were identified.
Results: Of 4,861 procedures, there were 4,025 SAVR and 836 TAVR. Patients receiving TAVR were noticeably older and had a higher logistic EuroSCORE as well as more pre-existing conditions. While unadjusted in-hospital mortality was slightly worse for transapical TAVR compared to SAVR (6.00% vs 5.71%), transfemoral TAVR achieves better results, with self-expanding transfemoral TAVR being associated with a significantly lower in-hospital mortality than balloon-expandable transfemoral TAVR (2.41% vs 5.17%; p=0.039). After risk adjustment, in-hospital mortality was significantly in favor of both balloon-expandable and self-expanding transfemoral TAVR vs SAVR (balloon-expandable: adjusted OR=0.50 [95% CI 0.27; 0.94], p=0.031; self-expanding: OR=0.20 [0.10; 0.41], p<0.001). Also in-hospital complication rates (stroke, major bleeding, delirium, mechanical ventilation >48h) were significantly better in TAVR. Furthermore, length of hospital stay was significantly shorter in TAVR than SAVR (transapical: adjusted Coefficient (Coeff)=-4.75d [-7.05d; -2.46d], p<0.001; balloon-expandable: Coeff=-6.88d [-9.06d; -4.69d], p<0.001; self-expanding: Coeff=-7.22 [-8.95; -5.49], p<0.001). Reimbursement showed mixed results.
Conclusion: In treatment of aortic regurgitation, TAVR is a feasible alternative for SAVR in selected patients, with overall lower in-hospital mortality and complication rates, particularly in favor of self-expanding transfemoral TAVR.

Figure: Standardized rates of in-hospital outcomes of patients with pure aortic regurgitation in 2018–2020

BE: balloon-expandable; CI: confidence interval; SAVR: surgical aortic valve replacement; SE: self-expanding; TA: transapical; TAVR: transcatheter aortic valve replacement; TF: transfemoral.