The David operation is a surgical procedurecommonly performed in patients with aortic root pathology and a normal, pliableaortic valve. During long-term follow-up, progressive degeneration of thenative valve may lead to pure aortic regurgitation (AR). Recently, the AURORAanatomical classification system and dual-anchoring concept were proposed tooptimize transcatheter aortic valve replacement (TAVR) strategies in patientswith pure AR [EuroIntervention 2025;21:952–960]. This study aimed to evaluatethe feasibility, efficacy, and safety of TAVR for pure AR after a prior Davidoperation using the AURORA classification.

Anatomical assessment was performed usingcomputed tomography to evaluate potential anchoring zones in the leftventricular outflow tract (LVOT), anatomical annulus, and ascending aorta.Based on the ability to achieve adequate theoretical anchoring (≥10%oversizing) in these three zones, patients were classified into four AURORAanatomical types. The primary efficacy endpoint was device success; primarysafety endpoints included 30-day mortality and major complications.

Eight patients were included: three withtype 1 anatomy, three with type 2, and two with type 4. The mean age was 59.3 ±5.2 years. Device success was achieved in all type 1 patients (3/3, 100%) andin one of three type 2 patients (33%), with no procedural mortality. Both type4 patients (2/2, 100%) underwent TAVR using a dedicated J-valve, achievingcomplete device and clinical success. One case of device failure occurred inlater procedures.

The AURORA classification enablessystematic anatomical assessment that may facilitate favorable TAVR outcomes inselected patients with pure AR after a David operation, particularly in type 1anatomy. Given the limited anchoring strength within the Dacron graft andnative annulus/LVOT after the David procedure, dedicated transcatheter heartvalves such as the J-valve or JenaValve are strongly recommended for otheranatomical types.