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

Aortic regurgitation (AR) is progressive and frequently under-recognized; without timely intervention it drives adverse left-ventricular remodeling and heart failure. Despite Class I guideline indications, many patients-especially older, frail individuals with multimorbidity-remain untreated. Advancements in high-fidelity multimodality imaging-including cardiac magnetic resonance, 4-dimensional flow, and speckle-tracking echocardiography-have enabled earlier detection of remodeling and more accurate quantification of regurgitant burden. These techniques are redefining thresholds for treatment and may enable biomarker-imaging composite staging of disease. Surgery remains the gold standard of therapy for native AR. Contemporary surgical management is tailored to age, anatomy, and root pathology. Although surgical aortic valve replacement remains the predominant therapy for most candidates, valve-sparing root procedures, the Ross operation, and aortic valve neocuspidization are increasingly offered at experienced centers for carefully selected lower-risk patients. Transcatheter aortic valve replacement is expanding rapidly as a viable option that helps bridge the treatment gap for those at prohibitive or high risk for surgery. Yet, devices optimized for calcific aortic stenosis encounter technical obstacles in native AR-including large, noncalcified annuli, elliptical root geometry, and high stroke volumes-leading to suboptimal anchoring, residual paravalvular regurgitation, and device embolization. Purpose-built AR systems with leaflet-engaging anchoring and enhanced sealing have shown encouraging outcomes in feasibility and pivotal studies and have obtained commercial approval in Europe, and U.S. authorization is anticipated. This state-of-the-art review synthesizes current insights into AR pathophysiology, diagnostic advances, and therapeutic innovations in surgical and transcatheter techniques, highlighting knowledge gaps and proposing research priorities to accelerate access to care for this historically undertreated population.