Tricuspid regurgitation has long been an overlooked condition within structural cardiology, despite its well-recognized impact on long-term clinical outcomes. As highlighted by Ayuba et al., TR is relatively frequent in the general population (3–6%) and even more prevalent among patients with heart failure (23%). Over recent years, a major paradigm shift has occurred: TR is now understood as a progressive disease that leads to systemic congestion, right ventricular (RV) dysfunction, functional decline, and increased mortality. Identifying appropriate candidates for TR reduction has thus become crucial to modify its natural course.
Although surgery remains the standard approach for symptomatic severe TR, most patients are elderly, present late with advanced symptoms and significant RV dysfunction, pulmonary hypertension, or comorbidities that make them poor surgical candidates. Reported surgical mortality remains high, ranging from 6% to 10%, and surgery is typically limited to younger, low-risk patients (TRI-SCORE <4) with preserved RV function. In practice, most patients—elderly, frail, and comorbid—receive long-term diuretic therapy, often as a palliative measure.
This therapeutic void between surgery and medical therapy has fostered the development of percutaneous tricuspid valve interventions.
- Transcatheter edge-to-edge repair (T-TEER)
Among the available options, edge-to-edge repair using devices such as the Abbott TriClip® and Edwards PASCAL® has gained the most clinical experience.
The TRILUMINATE Pivotal and CLASP TR trials demonstrated that T-TEER can reduce TR to moderate or less in 80–90% of patients, leading to significant symptom relief and quality-of-life improvement, with Kansas City Cardiomyopathy Questionnaire (KCCQ) score increases of +12 to +18 points. However, no survival benefit was demonstrated, and anatomical suitability remains a limitation. Broad coaptation gaps (>7–8 mm), restricted leaflet mobility, or massive annular dilation may preclude effective repair.
Consequently, up to one third of patients evaluated for T-TEER are deemed unsuitable for anatomical reasons, prompting the development of transcatheter tricuspid valve replacement.
- Transcatheter tricuspid valve replacement: the EVOQUE system
The Edwards EVOQUE® system represents the first orthotopic percutaneous replacement platform approved in both Europe and the United States. Its self-expanding design allows near-complete elimination of regurgitation by anchoring the valve to the native annulus and adjacent atrial tissue.
Early experiences, including the first-in-human study by Webb et al. and the TRISCEND trial, demonstrated procedural success rates of 95–98%, with almost complete TR elimination and improved functional capacity (70% of patients in NYHA I–II at one year).
The randomized TRISCEND II trial marked a turning point by comparing EVOQUE replacement with medical therapy. EVOQUE achieved a significant improvement in symptoms, functional capacity, and quality of life (mean KCCQ improvement of +23.1 points, with 10.2% of patients reaching NYHA I), although mortality rates did not differ significantly (12.6% with EVOQUE vs 15.2% with medical therapy).
The procedure carries procedural risks, including major bleeding in 15% and pacemaker implantation in 17% of patients, underscoring the importance of careful patient selection.
- Percutaneous annuloplasty systems
Annuloplasty devices aim to reduce annular dimensions, improving leaflet coaptation. Their main limitations include severely dilated annuli and unfavorable coronary sinus anatomy. Current studies demonstrate efficacy in functional TR with preserved valvular and subvalvular integrity, though no randomized trials have shown clinical benefit.
- Heterotopic valves
Heterotopic valve systems, primarily the TricValve® (the only one with CE mark approval), are designed to relieve venous congestion and, consequently, symptoms. These systems do not correct the valvular defect directly but offer relative anatomical independence, providing a palliative option for patients unsuitable for repair or replacement due to unfavorable anatomy.
- Patient selection: beyond clinical profile
As emphasized by Ayuba et al., successful tricuspid percutaneous therapy depends on comprehensive, multidisciplinary assessment.
The ideal candidate meets several criteria:
– Predominantly functional etiology with annular dilation and tethering but preserved leaflet integrity.
– Advanced symptoms (NYHA III–IV) despite optimal medical therapy.
– Preserved or mildly reduced RV function (TAPSE ≥13 mm, S′ ≥8 cm/s).
– Pulmonary systolic pressure <60 mmHg without advanced pulmonary disease.
– Favorable anatomy without thrombi or device interference.
– Adequate venous access and absence of terminal hepatic disease or cachexia.
For T-TEER, leaflet mobility and adequate coaptation are essential, whereas TTVR with EVOQUE® is preferred for massive or torrential TR with wide coaptation gaps or extremely dilated annuli, where repair would be ineffective. Heterotopic valves are currently reserved for anatomically unsuitable patients for both prior techniques, serving mainly a palliative role.
COMMENTARY:
The therapeutic landscape for tricuspid regurgitation has changed profoundly. Once considered an orphan disease, TR has now become a frontier of structural innovation.
Percutaneous therapies—both repair and replacement—have demonstrated substantial symptomatic and quality-of-life benefits, although their prognostic impact remains to be established. Individualized selection, accurate RV functional assessment, and integration of multimodal imaging are essential to balance clinical benefit and procedural risk.
As summarized by Ayuba et al., the future of tricuspid intervention will rely not only on device evolution but on our ability to identify the right patient for the right therapy at the right time.
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