Aortic regurgitation (AR) is a valvular disorder that is frequently underdiagnosed and, in the absence of early treatment, leads to adverse left ventricular remodeling and heart failure. Despite clear recommendations in clinical practice guidelines, treatment remains markedly underused, particularly in older patients and those with comorbidities.

Over the past decade, advances in multimodality imaging, including advanced echocardiography, cardiac magnetic resonance (CMR), and computed tomography, have enabled more accurate quantification of regurgitant severity and earlier detection of myocardial deterioration. These developments are redefining treatment thresholds, shifting the paradigm away from traditional symptom- and dimension-based criteria toward more individualized strategies based on volumetric assessment, myocardial strain, and fibrosis.

Surgical treatment remains the reference standard. Surgical aortic valve replacement (SAVR) continues to be the predominant option, although valve-preserving strategies such as aortic valve repair, valve-sparing root replacement, and the Ross procedure are gaining increasing relevance in specialized centers, particularly in younger patients.

At the same time, transcatheter aortic valve replacement (TAVR) is emerging as a promising alternative in high-risk or inoperable patients. However, its use in native AR remains technically challenging because of the absence of calcification and the anatomical features of the aortic annulus. The development of dedicated devices for AR has yielded encouraging results and may substantially expand the available therapeutic options.

Overall, contemporary AR management is moving toward a personalized strategy based on the integration of advanced imaging, anatomic characteristics, and patient profile, with an increasing tendency toward earlier intervention and a multidisciplinary approach.

COMMENTARY:

This review provides a robust and up-to-date overview of AR management, particularly highlighting the paradigm shift toward a more individualized, imaging-guided approach. AR is characterized by a prolonged subclinical phase. Traditional criteria based on symptoms and ejection fraction, which have historically dictated the timing of intervention, appear increasingly limited, and the review offers alternative tools to guide treatment timing more precisely.

In this regard, the article underscores the role of multimodality imaging, especially cardiac magnetic resonance and myocardial strain, as tools capable of identifying early ventricular remodeling. This is consistent with the growing body of evidence suggesting that once conventional parameters such as LVEF become abnormal, myocardial damage may already be irreversible. Indeed, it has been proposed that current thresholds may be identifying a relatively late stage of the disease, which would support a move toward earlier intervention.

However, the key question is whether earlier treatment truly improves prognosis. The available data are heterogeneous. Classic studies did not find significant differences between early surgery and conservative management in asymptomatic patients, provided that follow-up was close and surgery was performed at the appropriate time. More recent evidence, however, is reshaping this view. A contemporary meta-analysis suggests that early surgery in asymptomatic severe AR is associated with a significant reduction in all-cause mortality. Likewise, observational studies in patients with ventricular dilatation have shown better long-term survival when intervention is performed before overt functional deterioration develops.

This debate is not unique to AR, but rather reflects a broader trend across valvular heart disease. In aortic stenosis, for example, several meta-analyses have shown that early surgery in asymptomatic patients reduces heart failure hospitalizations. Even recent TAVR trials in asymptomatic patients point toward a reduction in clinical events compared with conservative management, suggesting that the paradigm of earlier intervention may also be applicable across different valvular conditions.

From a surgical standpoint, this paradigm shift has important implications. The expansion of valve repair techniques, valve-sparing surgery, and procedures such as the Ross operation reinforces the rationale for intervening earlier, in a setting of less structural damage and a greater likelihood of durable long-term success. In addition, the development of dedicated transcatheter devices for AR may lower the threshold for intervention in high-risk patients, further broadening the concept of early treatment.

In conclusion, this article accurately reflects a transitional moment in the management of aortic regurgitation: from a reactive strategy based on symptom onset to a proactive strategy grounded in early detection of myocardial damage. Although the evidence still has limitations and remains somewhat heterogeneous, the overall direction is clear: earlier intervention may improve outcomes, provided that patient selection is appropriate and surgical risk is carefully controlled. The future challenge will be to integrate advanced imaging, biomarkers, and robust clinical trials to define more precisely the optimal timing of intervention in this disease.

REFERENCE:

Pawar S, Allen C, Mori M, Markel J, Patel K, Thornton G, et al. Contemporary Diagnosis and Treatment of Aortic Regurgitation: A State-of-the-Art Review. J Am Coll Cardiol. 2026 Feb 3;87(4):385-413. doi: 10.1016/j.jacc.2025.10.026. Epub 2025 Oct 28. PMID: 41194752.