Tricuspid Regurgitation

EVOQUE Tricuspid Valve Replacement System: State-of-the-Art Screening and Intraprocedural Guidance

With the recent approval of the transcatheter EVOQUE tricuspid valve replacement system to treat severe, symptomatic tricuspid regurgitation, there is a need to define the appropriate patient population and anatomical considerations for this device. In this consensus document, the authors review these considerations, describe the procedural steps and imaging requirements to ensure technical success, and discuss management of complex intraprocedural circumstances.

First Case of the Treatment of Massive Tricuspid Regurgitation With the CroíValve DUO Coaptation Valve in a Patient With a Right Ventricular Pacemaker Lead

Background

Tricuspid regurgitation (TR) is a common valvular disorder with limited treatment options. It occurs when tricuspid leaflet closure is prevented by dilation of the right heart or in patients with cardiac implantable rhythm devices when the transvalvular lead impedes proper closure of the valve. The management of these patients can be complicated. The removal of the lead often does not improve the TR, and surgical repair is usually not possible because of comorbidities. A number of percutaneous TR repair and replacement devices have been developed; however, the presence of the right ventricular lead can prevent the delivery of these devices, or the device may displace the pacemaker lead. We report the first implant of the CroíValve DUO Transcatheter Tricuspid Coaptation Valve System (Dublin, Ireland) in a patient with massive TR and a right ventricular lead.

Methods

The patient was not a fit for surgical treatment and underwent transcatheter treatment following compassionate use approval. The procedure was performed under general anesthetic with echo and X-ray guidance. The device was delivered through the right internal jugular vein.

Results

The device was implanted successfully, and the TR was reduced from massive to mild at 90-day follow-up. The patient's quality of life improved significantly with an improvement in 6-minute walk test (382 m at baseline to 467 m at follow-up), the New York Heart Association classification (III at baseline to I at follow-up), and the Kansas City Cardiomyopathy Questionnaire (baseline score 43 increased to 60). The efficacy and clinical improvement have been stable over the past 90 days of follow-up, and the patient has not suffered any adverse events.

Conclusions

This is the first implantation of the CroíValve DUO Coaptation Valve System in a patient with a pacemaker lead. In these patients, this device may offer advantages over other current transcatheter approaches.

Structural Cardiac Interventions in Patients With Heart Failure: JACC Scientific Statement

Pathologic left ventricular remodeling and valvular heart disease may contribute to the clinical presentation and outcomes of patients presenting with heart failure, and limit the effectiveness of guideline-directed medical therapy. Although surgical interventions including surgical ventricular restoration techniques and valve repair or replacement are effective therapies, there is growing evidence that transcatheter interventions may be options for patients with persistent symptoms of heart failure despite optimal medical therapy, where surgical options may be limited. This scientific statement will review the current available and investigational percutaneous strategies for the management of structural contributors to heart failure: dilated left ventricular cardiomyopathies and valvular heart disease.

Dynamic evolution of tricuspid regurgitation during hospitalization in patients with acute decompensated heart failure

AIMS

Secondary tricuspid regurgitation (TR) is associated with poor prognosis in acute decompensated heart failure (ADHF). However, its dynamic evolution in response to volume status and treatment has never been previously investigated. In this study, we sought to explore the in-hospital evolution of TR in ADHF patients and to assess its prognostic implications.

METHODS AND RESULTS

We retrospectively enrolled patients admitted for ADHF with ≥2 in-hospital echocardiographic evaluations of TR. Patients were categorized, according to TR evolution, into persistent moderate-severe TR, improved TR (from moderate-severe to trivial-mild) and persistent trivial-mild TR. The primary endpoint was a composite of 5-year all-cause mortality and heart failure hospitalization (HFH). A total of 1054 patients were included. Of 318 patients (30%) with moderate-severe TR at admission, 49% improved TR severity and showed better trends of decongestion, whereas those who maintained persistent moderate-severe TR had characteristics of more severe heart failure at admission and discharge. Atrial fibrillation, previous heart failure and higher dosage of loop diuretics before admission were associated with a lower probability of improved TR. After adjustment, improved TR was associated with lower risk of 5-year all-cause mortality/HFH compared with persistent moderate-severe TR (hazard ratio [HR] 0.524, p = 0.008) and no different from persistent trivial-mild TR (HR 0.878, p = 0.575). Results were consistent across all subgroups of in-hospital variation of mitral regurgitation.

CONCLUSION

Among ADHF patients with moderate-severe TR at admission, 49% had an in-hospital improvement in TR severity, which was associated with a reduction in risk of 5-year all-cause mortality and morbidity outcomes.

Secondary tricuspid regurgitation: incidence, types, and outcomes in atrial fibrillation vs. sinus rhythm

BACKGROUND AND AIMS

Incidence and types of secondary tricuspid regurgitation (TR) are not well defined in atrial fibrillation (AFib) and sinus rhythm (SR). Atrial secondary TR (A-STR) is associated with pre-existing AFib; however, close to 50% of patients with A-STR do not have AFib. The aim of this study was to assess incidence, types, and outcomes of ≥ moderate TR in AFib vs. SR.

METHODS

Adults with and without new-onset AFib without structural heart disease or ≥ moderate TR at baseline were followed for the development of ≥ moderate TR. Tricuspid regurgitation types were pacemaker, left-sided valve disease, left ventricular (LV) dysfunction, pulmonary hypertension (PH), isolated ventricular, and A-STR.

RESULTS

Among 1359 patients with AFib and 20 438 in SR, 109 and 378 patients developed ≥ moderate TR, respectively. The individual types of TR occurred more frequently in AFib related to the higher pacemaker implantation rates (1.12 vs. 0.19 per 100 person-years, P < .001), larger right atrial size (median 78 vs. 53 mL, P < .001), and higher pulmonary pressures (median 30 vs. 28 mmHg, P < .001). The most common TR types irrespective of rhythm were LV dysfunction-TR and A-STR. Among patients in SR, those with A-STR were older, predominantly women with more diastolic abnormalities and higher pulmonary pressures. All types of secondary TR were associated with all-cause mortality, highest in PH-TR and LV dysfunction-TR.

CONCLUSIONS

New-onset AFib vs. SR conferred a higher risk of the individual TR types related to sequelae of AFib and higher pacemaker implantation rates, although the distribution of TR types was similar. Secondary TR was universally associated with increased mortality.

Comparing outcomes of transcatheter tricuspid valve replacement and medical therapy for symptomatic severe tricuspid regurgitation: a retrospective study

BACKGROUND

Impaired hospitalizations for heart failure (HHF) and mortality are associated with tricuspid regurgitation (TR).

OBJECTIVES

The objective of this study was to investigate the benefit of transcatheter tricuspid valve replacement (TTVR) over guideline-directed medical therapy (GDMT) in patients with symptomatic severe TR.

METHODS

Between May 2020 and April 2023, 88 patients with symptomatic severe TR were treated in our center. Of these, 57 patients received GDMT alone, and 31 patients underwent combined TTVR and GDMT. We collected and analyzed baseline data, and follow-up information for both groups. The primary endpoints were all-cause mortality and the combined endpoint (including all-cause mortality and HHF).

RESULTS

At a median follow-up of 20 (IQR 10-29) months, significant improvements were shown in TR severity, right ventricular function, and dimensions in TTVR group (all P < 0.001). It also resulted in superior survival rates (75.8% vs. 48.4%, P = 0.019), improved freedom from combined endpoint (61.5% vs. 45.9%, P = 0.007) and fewer major adverse events. After stratification by TRI-SCORE, the subgroup with < 6 points in the TTVR group exhibited a significant difference in the combined endpoint compared to the other subgroups (all P < 0.05), while no significant differences were observed in the GDMT subgroups (P = 0.680).

CONCLUSIONS

The utilization of LuX-Valve in TTVR effectively improves TR and is associated with lower rates of major adverse events, HHF and all-cause mortality. The TRI-SCORE may help identify higher-benefit patients with TR from TTVR. Clinical trial registration ClinicalTrials.gov Protocol Registration System (NCT02917980).

Transcatheter tricuspid valve interventions: Current devices and clinical evidence

The tricuspid valve is known as "the forgotten valve". Tricuspid regurgitation (TR) is a highly prevalent valvular heart disease. TR is often late in the course of the disease when it becomes symptomatic, often being a marker of late-stage chronic heart failure with a poor prognosis and high mortality rate at long-term follow-up. Despite the clear correlation between TR and mortality, most TR patients are under-treated. Neither pharmacologic nor surgical treatment demonstrates a significant survival benefit. Isolated tricuspid valve surgery has the highest mortality rate of all valve surgeries. Therefore, there is an urgent clinical need for minimally invasive therapies to meet the needs of patients with TR. In recent years, a variety of transcatheter tricuspid valve interventions representing less invasive alternatives to surgery have shown promising results, which bring hope to patients with severe TR. The purpose of this review is to provide a complete and updated overview on current transcatheter tricuspid valve interventions and clinical evidence.

Most hospitalized patients with significant tricuspid regurgitation have advanced disease preventing transcatheter tricuspid valve intervention

BACKGROUND

More than moderate tricuspid regurgitation (TR) is associated with high mortality. Surgical tricuspid valve repair and replacements are rarely performed due to high operative mortality risk, mainly attributed to late presentation. Novel transcatheter tricuspid valve intervention (TTVI) devices are being developed as an alternative to surgery. The population of patients presenting to tertiary care centers who can benefit from TTVI has not been well defined.

METHODS

We retrospectively analyzed 12,677 consecutive 2D echocardiograms completed at our tertiary care center between March 2021 and March 2022 and identified hospitalized patients with more than moderate TR. A total of 569 patients were included in this study. Clinical and echocardiographic data were collected by individual chart review. We used the European Society of Cardiology (ESC) guidelines on the management of valvular disease to retrospectively assign patients to medical, surgical, or transcatheter therapy.

RESULTS

458 patients (80.5 %) were assigned to medical therapy, 57 (10.0 %) were assigned to TTVI, and 54 (9.5 %) were assigned to tricuspid valve surgery. Of note, 75.7 % (431/569) of patients were precluded from any intervention due to advanced disease, and only 4.7 % (27/569) presented too early for intervention, being both asymptomatic and without RV dilatation.

CONCLUSION

Only 10.0 % of patients presenting to a tertiary care center with significant TR would be candidates for TTVI when these technologies are approved in the United States. Earlier identification and treatment of TR could increase the number of patients who may benefit from interventions including TTVI.

Assessment of Tricuspid Regurgitation by Cardiac Magnetic Resonance Imaging: Current Role and Future Applications

Tricuspid regurgitation (TR) is a prevalent valvular disease with a significant mortality rate. The evaluation of TR severity and associated right heart remodeling and dysfunction is crucial to determine the optimal therapeutic strategy and to improve prognosis. While echocardiography remains the first-line imaging technique to evaluate TR, it has many limitations, both operator- and patient-related. Cardiovascular magnetic resonance imaging (CMR) has emerged as an innovative and comprehensive non-invasive cardiac imaging technique with additional value beyond routine echocardiographic assessment. Besides its established role as the gold standard for the evaluation of cardiac volumes, CMR can add important insights with regard to valvular anatomy and function. Accurate quantification of TR severity, including calculation of regurgitant volume and fraction, can be performed using either the well-known indirect volumetric method or novel 4D flow imaging. In addition, CMR can be used to assess the impact on the right heart, including right heart remodeling, function and tissue characterization. Several CMR-derived parameters have been associated with outcome, highlighting the importance of multi-modality imaging in patients with TR. The aim of this review is to provide an overview of the current role of CMR in the assessment and management of patients with TR and its future applications.

Prevalence, Incidence, and Outcomes of Diastolic Dysfunction in Isolated Tricuspid Regurgitation: Perhaps Not Really "Isolated"?

BACKGROUND

In the absence of left-sided cardiac/pulmonary disease, functional tricuspid regurgitation (FTR) is referred to as isolated or idiopathic. Relationships between left ventricular diastolic dysfunction (DD) and FTR remain unknown.

OBJECTIVES

The purpose of this study was to investigate the prevalence, incidence, and outcome of DD in patients with idiopathic FTR.

METHODS

Adults without structural heart disease were identified. Severe DD was defined by ≥3 of 4 abnormal DD parameters (medial e', medial E/e', TR velocity, left atrial volume index) and ≥ moderate DD by ≥2. Propensity-score matching was performed (3:1) between each less-than-severe TR group and severe TR based on age, sex, body mass index, and comorbidities.

RESULTS

Among 30,428 patients, FTR was absent in 73%, mild in 22%, moderate in 4%, and severe in 0.4%. In the propensity-matched sample, severe DD was present in 2%, 6%, 9%, and 13% patients, and ≥ moderate DD in 11%, 18%, 28%, and 48%, respectively (P < 0.001). The probability of heart failure with preserved ejection fraction using the H2FPEF score increased with increasing FTR (median 29.7%, 45.5%, 61.4%, and 88.7%, respectively), as did the prevalence of impaired left atrial strain <24% (35%, 48%, and 69% in mild, moderate, and severe TR). Incident severe and ≥ moderate DD developed more frequently with increasing FTR (HR: 8.45 [95% CI: 2.60-27.50] and HR: 2.82 [95% CI: 1.40-5.69], respectively for ≥ moderate vs no FTR) over a median of 3.0 years. Findings were confirmed in patients without lung disease or right ventricular enlargement. Over a median of 5.0 years, patients with ≥ moderate FTR and DD had the greatest risk of worse outcomes (multivariable P < 0.001). The association between TR and adverse outcomes was significantly diminished in the absence of DD.

CONCLUSIONS

Diastolic dysfunction, increased heart failure with preserved ejection fraction probability, and impaired left atrial strain are commonly present in patients with idiopathic FTR, suggesting that the latter may not be truly isolated. Patients with FTR without DD or heart failure are at increased risk of incident DD. Patients with FTR and DD display worse outcomes.

Advances in the Assessment of Patients With Tricuspid Regurgitation: A State-of-the-Art Review on the Echocardiographic Evaluation Before and After Tricuspid Valve Interventions

Tricuspid regurgitation (TR) can have a significant impact on the health and mortality of a patient. Unfortunately, many patients with advanced right-sided heart failure are not referred for isolated tricuspid valve (TV) surgery in a timely manner. This delayed referral has resulted in a high in-hospital mortality rate and significant undertreatment. Fortunately, transcatheter TV intervention (TTVI) has emerged as a safe and effective alternative to surgery, successfully reducing TR severity and improving patients' quality of life. Current guidelines emphasize the importance of assessing TR severity and its impact on the right heart chambers for selecting the appropriate intervention. However, the echocardiographic assessment of both right chambers and TV anatomy, along with TR severity, poses specific challenges, leading to the underestimation of TR severity. Recently, three-dimensional echocardiography has become crucial to enhance the characterization of TR severity. Moreover, it is essential to evaluate residual TR after TTVI to gauge the intervention's success and predict the patient's prognosis. This review provides a thorough evaluation of the echocardiographic parameters used to assess TR severity before and after TTVI. It presents a critical analysis of the accuracy and reliability of these parameters, highlighting their strengths and limitations to establish standardized diagnostic criteria and treatment protocols for TR, which will inform clinical decision-making and improve patient outcomes.

Modified Clover Technique Using Automated Suture Placement and Securing Technology in a Passive Beating Heart Model

Tricuspid regurgitation (TR) is a prevalent finding in echocardiography and in case of severe disease is associated with impaired patient outcome. Clover repair offers a surgical solution that can be applied for the treatment of primary and secondary TR. An ex vivo passive beating porcine heart model was created to test a modified clover technique using automated suturing devices and to compare this approach to standard ring annuloplasty. Secondary TR was induced in 10 porcine hearts and the backflow of fluid was assessed. The primary endpoint of this study was regurgitant volume measured in mL at the site right atrial cannula. The baseline regurgitation was 43.3 ± 10.8 mL. The mean regurgitant volume was significantly reduced after all repair procedures to 22.2 ± 5.9 mL with isolated ring annuloplasty, 12 ± 3.9 mL with the modified clover, and 7.6 ± 3.4 mL with the combined procedure (p < 0.0001). The modified clover technique shows how to effectively reduce TR in an ex vivo model. This method may be suitable to facilitate tricuspid repair, especially for totally endoscopic valve surgery.

Right Heart Remodeling and Outcomes in Patients With Tricuspid Regurgitation: A Literature Review and Meta-Analysis

BACKGROUND

Functional tricuspid regurgitation (TR) can develop either because of right ventricular (RV) remodeling (ventricular functional TR) and/or right atrial dilation (atrial functional TR).

OBJECTIVES

This meta-analysis aimed to investigate the association between right heart remodeling and long-term (>1 year) all-cause mortality in patients with significant TR (at least moderate, ≥2+).

METHODS

MEDLINE, ISI Web of Science, and SCOPUS databases were searched. Studies reporting data on at least 1 RV functional parameter and long-term all-cause mortality in patients with significant TR were included. This study was designed according to PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) requirements.

RESULTS

Out of 8,902 studies, a total of 14 were included, enrolling 4,394 subjects. The duration of follow-up across the studies varied, ranging from a minimum of 15.5 months to a maximum of 73.2 months. Overall, long-term all-cause mortality was 31% (95% CI: 20%-41%; P ≤ 0.001). By means of meta-regression analyses, an inverse relation was found between tricuspid annular plane systolic excursion (11 studies enrolling 3,551 subjects, -6.3% [95% CI: -11.1% to -1.4%]; P = 0.011), RV fractional area change (9 studies, 2,975 subjects, -4.4% [95% CI: -5.9% to -2.9%]; P < 0.001), tricuspid annular dimension (7 studies, 2,986 subjects, -4.1% [95% CI: -7.6% to -0.5%]; P = 0.026), right atrial area (6 studies, 1,920 subjects, -1.9% [95% CI: -2.5% to -1.3%]; P < 0.001) and mortality.

CONCLUSIONS

RV dysfunction parameters are associated to worse clinical outcomes in patients with TR, whereas right atrial dilatation is linked to a better prognostic outcome. Further studies are needed to unravel the pathophysiological differences within the functional TR spectrum. (Right heart remodeling and outcomes in patients with tricuspid regurgitation; CRD42023418667).

Transcatheter Therapy for the Tricuspid Valve: A Focused Review of Edge-to-Edge Repair and Orthotopic Valve Replacement

PURPOSE OF REVIEW

Patients with severe tricuspid regurgitation (TR) are at risk for significant morbidity and mortality. Transcatheter tricuspid valve interventions (TTVI) may offer patients less invasive treatment alternatives to surgery. This review evaluates the most common class of device currently used worldwide to treat TR, tricuspid transcatheter edge-to-edge repair (T-TEER) and orthotopic transcatheter tricuspid valve replacement (TTVR), both of which are now approved in the USA and Europe.

RECENT FINDINGS

The first pivotal randomized clinical trial, TRILUMINATE, demonstrated that T-TEER can safely reduce TR and is associated with improved health status outcomes. However, results of this trial have raised questions about whether this device can provide sufficient TR reduction to impact clinical outcomes. Orthotopic TTVR has recently gained attention with initial data suggesting near-complete TR elimination. The current review examines the technical features and anatomic limitations of the most commonly used devices for T-TEER and orthotopic TTVR, discusses the current clinical data for these devices, and offers a theoretical construct for device selection.

Determinants of Tricuspid Regurgitation Progression and Its Implications for Adequate Management

BACKGROUND

Tricuspid regurgitation (TR) is associated with an increased mortality. Previous studies have analyzed predictors of TR progression and the clinical impact of baseline TR. However, there is a lack of evidence regarding the natural history of TR: the pattern of change and clinical impact of progression.

OBJECTIVES

The authors sought to evaluate predictors of TR progression and assess the prognostic impact of TR progression.

METHODS

A total of 1,843 patients with at least moderate TR were prospectively followed up with consecutive echocardiographic studies and/or clinical evaluation. All patients with less than a 2-year follow-up were excluded. Clinical and echocardiographic features, hospitalizations for heart failure, and cardiovascular death and interventions were recorded to assess their impact in TR progression.

RESULTS

At a median 2.3-year follow-up, 19% of patients experienced progression. Patients with baseline moderate TR presented a rate progression of 4.9%, 10.1%, and 24.8% 1 year, 2 years, and 3 years, respectively. Older age (HR: 1.03), lower body mass index (HR: 0.95), chronic kidney disease (HR: 1.55), worse NYHA functional class (HR: 1.52), and right ventricle dilation (HR: 1.33) were independently associated with TR progression. TR progression was associated with an increase in chamber dilation as well as a decrease in ventriculoarterial coupling and in left ventricle ejection fraction (P < 0.001). TR progression was associated with an increased cardiovascular mortality and hospitalizations for heart failure (P < 0.001).

CONCLUSIONS

Marked individual variability in TR progression hindered accurate follow-up. In addition, TR progression was a determinant for survival regardless of initial TR severity.

2024 update in heart failure

In the last years, major progress has occurred in heart failure (HF) management. The 2023 ESC focused update of the 2021 HF guidelines introduced new key recommendations based on the results of the last years of science. First, two drugs, sodium-glucose co-transporter-2 (SGLT2) inhibitors and finerenone, a novel nonsteroidal, selective mineralocorticoid receptor antagonist (MRA), are recommended for the prevention of HF in patients with diabetic chronic kidney disease (CKD). Second, SGLT2 inhibitors are now recommended for the treatment of HF across the entire left ventricular ejection fraction spectrum. The benefits of quadruple therapy in patients with HF with reduced ejection fraction (HFrEF) are well established. Its rapid and early up-titration along with a close follow-up with frequent clinical and laboratory re-assessment after an episode of acute HF (the so-called 'high-intensity care' strategy) was associated with better outcomes in the STRONG-HF trial. Patients experiencing an episode of worsening HF might require a fifth drug, vericiguat. In the STEP-HFpEF-DM and STEP-HFpEF trials, semaglutide 2.4 mg once weekly administered for 1 year decreased body weight and significantly improved quality of life and the 6 min walk distance in obese patients with HF with preserved ejection fraction (HFpEF) with or without a history of diabetes. Further data on safety and efficacy, including also hard endpoints, are needed to support the addition of acetazolamide or hydrochlorothiazide to a standard diuretic regimen in patients hospitalized due to acute HF. In the meantime, PUSH-AHF supported the use of natriuresis-guided diuretic therapy. Further options and most recent evidence for the treatment of HF, including specific drugs for cardiomyopathies (i.e., mavacamten in hypertrophic cardiomyopathy and tafamidis in transthyretin cardiac amyloidosis), device therapies, cardiac contractility modulation and percutaneous treatment of valvulopathies, with the recent finding from the TRILUMINATE Pivotal trial, are also reviewed in this article.

Paravalvular Leak Closure After Transcatheter Tricuspid Valve-in-Ring Implantation: A Case Report

Transcatheter tricuspid valve intervention (TTVI) has emerged as a promising alternative for patients with severe tricuspid regurgitation who are deemed high-risk for surgery. With advancements in device design and delivery systems, TTVI has shown promising outcomes in reducing tricuspid regurgitation severity and improving symptoms in selected patients. Paravalvular leaks (PVLs) are one of the most common complications faced, which can significantly contribute to patients' morbidity and mortality. Percutaneous PVL closure represents a minimally invasive approach to address this issue, but its efficacy and safety in the context of transcatheter tricuspid valve-in-ring implantation require further elucidation. We describe the case of a 44-year-old lady with a history of rheumatic valve disease status post-tricuspid valve annuloplasty with an incomplete ring who presented to cardiology clinics with symptomatic torrential tricuspid regurgitation. Due to the high risk of surgical reintervention secondary to severe right ventricular (RV) failure, she was denied surgical intervention. Therefore, she underwent transcatheter tricuspid valve-in-ring (TVIR) implantation with a 26 mm MyVal (Meril Life Sciences Pvt Ltd., Vapi, GJ, IND), which was complicated by a residual severe tricuspid paravalvular regurgitation. The defect was subsequently closed by a dedicated Occlutech PVL device (Occlutech, Helsingborg, SWE) measuring 18 mm x 10 mm. Post which, the patient had trivial tricuspid regurgitation and significant improvement in signs and symptoms with subsequent follow-up.

Leadless Pacemaker Implantation Across Percutaneous Tricuspid Valve Prothesis Implanted Via Valve-in-Valve Technique

We present the case of an 82-year-old woman with history of bivalvular replacement (mitral mechanical prothesis and tricuspid bioprothesis) and subsequent tricuspid percutaneous valve-in-valve bioprothesis implantation. The patient developed an indication for pacemaker implantation. We describe the feasibility of leadless pacemaker implantation across the tricuspid prothesis when all other techniques fail.

Pacing and Defibrillation Consideration in the Era of Transcatheter Tricuspid Valve Replacement

PURPOSE OF REVIEW

Tricuspid regurgitation is a commonly encountered valvular pathology in patients with trans-tricuspid pacing or implantable cardioverter-defibrillator leads. Transcatheter tricuspid valve interventions are increasingly performed in patients at high surgical risk. Implantation of these valves can lead to the "jailing" of a trans-tricuspid lead. This practice carries both short- and long-term risks of lead failure and subsequent infection without the ability to perform traditional transvenous lead extraction. Herein, this manuscript reviews available therapeutic options for lead management in patients undergoing transcatheter tricuspid valve interventions.

RECENT FINDINGS

The decision to jail a lead may be appropriate in certain high-risk cases, though extraction may be a better option in most cases given the variety of options for re-implant, including leadless pacemakers, valve-sparing systems, epicardial leads, leads placed directly through prosthetic valves, and the completely subcutaneous implantable-defibrillator. A growing number of patients meet the requirement for CIED implantation in the United States. A significant proportion of these patients will have tricuspid valve dysfunction, either related to or independent of their transvenous lead. As with any percutaneous intervention that has shown efficacy, the role of TTVI is also likely to increase as this therapy advances beyond the investigational phase. As such, the role of the heart team in the management of these patients will be increasingly critical in the years to come, and in those patients that have pre-existing CIED leads, we advocate for the involvement of an electrophysiologist in the heart team.

New Approaches to Assessment and Management of Tricuspid Regurgitation Before Intervention

Severe tricuspid regurgitation (TR) is a progressive condition associated with substantial morbidity, poor quality of life, and increased mortality. Patients with TR commonly have coexisting conditions including congestive heart failure, pulmonary hypertension, chronic lung disease, atrial fibrillation, and cardiovascular implantable electronic devices, which can increase the complexity of medical and surgical TR management. As such, the optimal timing of referral for isolated tricuspid valve (TV) intervention is undefined, and TV surgery has been associated with elevated risk of morbidity and mortality. More recently, an unprecedented growth in TR treatment options, namely the development of a wide range of transcatheter TV interventions (TTVI) is stimulating increased interest and referral for TV intervention across the entire medical community. However, there are no stepwise algorithms for the optimal management of symptomatic severe TR before TTVI. This article reviews the contemporary assessment and management of TR with addition of a medical framework to optimize TR before referral for TTVI.

Prediction of Mortality and Heart Failure Hospitalization After Transcatheter Tricuspid Valve Interventions: Validation of TRISCORE

BACKGROUND

Data on the prognostic role of the TRI-SCORE in patients undergoing transcatheter tricuspid valve intervention (TTVI) are limited.

OBJECTIVES

The aim of this study was to evaluate the performance of the TRI-SCORE in predicting outcomes of patients undergoing TTVI.

METHODS

TriValve (Transcatheter Tricuspid Valve Therapies) is a large multicenter multinational registry including patients undergoing TTVI. The TRI-SCORE is a risk model recently proposed to predict in-hospital mortality after tricuspid valve surgery. The TriValve population was stratified based on the TRI-SCORE tertiles. The outcomes of interest were all-cause death and all-cause death or heart failure hospitalization. Procedural complications and changes in NYHA functional class were also reported.

RESULTS

Among the 634 patients included, 223 patients (35.2%) had a TRI-SCORE between 0 and 5, 221 (34.8%) had 6 or 7, and 190 (30%) had ≥8 points. Postprocedural blood transfusion, acute kidney injury, new atrial fibrillation, and in-hospital mortality were more frequent in the highest TRI-SCORE tertile. Postprocedure length of stay increased with a TRI-SCORE increase. A TRI-SCORE ≥8 was associated with an increased risk of 30-day all-cause mortality and all-cause mortality and the composite endpoint assessed at a median follow-up of 186 days (OR: 3.00; 95% CI: 1.38-6.55; HR: 2.17; 95% CI: 1.78-4.13; HR: 2.08, 95% CI: 1.57-2.74, respectively) even after adjustment for procedural success and EuroSCORE II or Society of Thoracic Surgeons Predicted Risk of Mortality. The NYHA functional class improved across all TRI-SCORE values.

CONCLUSIONS

In the TriValve registry, the TRI-SCORE has a suboptimal performance in predicting clinical outcomes. However, a TRISCORE ≥8 is associated with an increased risk of clinical events and a lack of prognostic benefit after successful TTVI.

Hemodynamic Melody of Postnatal Cardiac and Pulmonary Development in Children with Congenital Heart Diseases

Hemodynamics is the eternal theme of the circulatory system. Abnormal hemodynamics and cardiac and pulmonary development intertwine to form the most important features of children with congenital heart diseases (CHDs), thus determining these children's long-term quality of life. Here, we review the varieties of hemodynamic abnormalities that exist in children with CHDs, the recently developed neonatal rodent models of CHDs, and the inspirations these models have brought us in the areas of cardiomyocyte proliferation and maturation, as well as in alveolar development. Furthermore, current limitations, future directions, and clinical decision making based on these inspirations are highlighted. Understanding how CHD-associated hemodynamic scenarios shape postnatal heart and lung development may provide a novel path to improving the long-term quality of life of children with CHDs, transplantation of stem cell-derived cardiomyocytes, and cardiac regeneration.

Contemporary evaluation and treatment of tricuspid regurgitation

Valvular heart disease is a global health burden with substantial mortality. The left-sided valvular diseases have been extensively described using the robust treatment strategies available. By contrast, the right-sided diseases, particularly the tricuspid valve (TV) and associated regurgitation, still have much to be delineated. Worsening tricuspid regurgitation (TR) is associated with increased mortality; the non-invasive management is suboptimal; and surgical approaches carry significant risk. With advances in multimodality imaging, 3D echocardiography, improved understanding of TV anatomy, and pathophysiological mechanisms of primary and secondary regurgitation, as well as favorable data with transcatheter therapies, the field of TV management is rapidly evolving. This review aims to highlight pathophysiological mechanisms of TR, describe echocardiographic approaches to diagnosis and TV interrogation, and outline the latest transcatheter developments.

A comprehensive overview of surgical and transcatheter therapies to treat tricuspid regurgitation in patients with heart failure

PURPOSE OF REVIEW

The unique pathophysiologic considerations of severe tricuspid regurgitation (TR) have led to advancements in surgical and transcatheter treatments. The purpose of this review is to highlight the current surgical and transcatheter tricuspid valve interventions (TTVI) to functional TR.

RECENT FINDINGS

Surgical repair with ring annuloplasty consistently demonstrates better outcomes than surgical replacement or other repair approaches. However, surgical uptake of TR correction remains relatively low, and operative mortality rates are still high owing to multiple comorbidities and advanced tricuspid valve disease/right ventricular dysfunction at time of referral. Pivotal trials for tricuspid transcatheter edge-to-edge repair (T-TEER) and transcatheter TV replacement (TTVR) indicate improved quality of life compared to medical therapy alone for high-surgical-risk patients with severe symptomatic TR. Trials are underway to assess caval valve implantation (CAVI), which holds hope for many severe TR patients who are not ideal candidates for T-TEER or orthotopic TTVR. Peri-procedural optimization of right ventricular function remains critical to promote both device success and patient outcomes.

SUMMARY

Clinical outcomes after surgical TV intervention are poor, often due to intervening late in the disease course of TR. TTVI covers a treatment gap for patients deemed inoperable or high-surgical-risk, but earlier referral for TV interventions is still important prior to patients developing multiorgan dysfunction from chronic untreated TR.

Cardiac Devices and Kidney Disease

A growing variety of cardiac devices are available to monitor or support cardiovascular function. The entwined nature of cardiovascular disease and kidney disease makes the relationship of these devices with kidney disease a multifaceted question relating to the use of these devices in individuals with kidney disease and to the effects of the devices and device placement on kidney health. Cardiac devices can be categorized broadly into cardiac implantable electronic devices, structural devices, and circulatory assist devices. Cardiac implantable electronic devices include devices for monitoring and managing cardiac electrical activity and devices for monitoring hemodynamics. Structural devices modify cardiac structure and include valve prostheses, valve repair clips, devices for treating atrial septal abnormalities, left atrial appendage closure devices, and interatrial shunt devices. Circulatory assist devices support the failing heart or support cardiac function during high-risk cardiac procedures. Evidence for the use of these devices in individuals with kidney disease, effects of the devices on kidney health and function, specific considerations with devices in kidney disease, and important knowledge gaps are surveyed in this article. With the growing prevalence of combined cardiorenal disease and the increasing variety of cardiac devices, kidney disease considerations are an important aspect of device therapy.

Transcatheter tricuspid valve replacement for functional tricuspid regurgitation after left-sided valve surgery: A single-center experience

BACKGROUND

Functional tricuspid regurgitation (FTR) following left-sided valve surgery (LSVS) is of clinical significance due to its high recurrence and mortality rates. Transcatheter therapy presents a potential solution to address this issue.

AIMS

The study aimed to assess the safety and efficacy of transcatheter tricuspid valve replacement using the Lux-Valve system in a single center for patients with FTR after LSVS.

METHODS

From June 2020 to April 2023, 20 patients with symptomatic severe FTR after LSVS were referred to our center. A multidisciplinary cardiac team evaluated these patients for suitability for transcatheter tricuspid valve replacement with Lux-Valve systems. Primary efficacy and safety endpoints were immediate postoperative tricuspid regurgitation severity ≤ moderate and major adverse events during follow-up.

RESULTS

Twenty patients (average age 65.7 ± 7.4 years; 65.0% women) successfully underwent Lux-Valve system implantation after LSVS. All patients achieved ≤ moderate tricuspid regurgitation immediately after the procedure. Only one patient (5.0%) experienced a procedure-related major adverse event, leading to in-hospital mortality due to pulmonary infection. At the 6-month follow-up, 17 patients (89.5%) improved to New York Heart Association functional class I to II (p < 0.001). The overall Kansas City Cardiomyopathy Questionnaire score significantly improved (35.9 ± 6.7 points to 58.9 ± 5.8 points, p < 0.001).

CONCLUSION

The Lux-Valve system was found to be safe and effective for treating FTR after LSVS. It resulted in positive early outcomes, including a significant reduction in FTR, improved functional status, and enhanced quality of life, especially in high-risk patients.

Characteristics and outcomes of patients with tricuspid regurgitation and advanced heart failure

AIMS

To evaluate the role of tricuspid regurgitation in advanced heart failure.

METHODS

The multicenter observational HELP-HF registry enrolled consecutive patients with heart failure and at least one 'I NEED HELP' criterion evaluated at four Italian centers between January 2020 and November 2021. Patients with no data on tricuspid regurgitation and/or receiving tricuspid valve intervention during follow-up were excluded. The population was stratified by no/mild tricuspid regurgitation vs. moderate tricuspid regurgitation vs. severe tricuspid regurgitation. Variables independently associated with tricuspid regurgitation, as well as the association between tricuspid regurgitation and clinical outcomes were investigated. The primary outcome was all-cause mortality.

RESULTS

Among the 1085 patients included in this study, 508 (46.8%) had no/mild tricuspid regurgitation, 373 (34.4%) had moderate tricuspid regurgitation and 204 (18.8%) had severe tricuspid regurgitation. History of atrial fibrillation, any prior valve surgery, high dose of furosemide, preserved left ventricular ejection fraction, moderate/severe mitral regurgitation and pulmonary hypertension were found to be independently associated with an increased likelihood of severe tricuspid regurgitation. Estimated rates of 1-year all-cause death were of 21.4, 24.5 and 37.1% in no/mild tricuspid regurgitation, moderate tricuspid regurgitation and severe tricuspid regurgitation, respectively (log-rank P  < 0.001). As compared with nonsevere tricuspid regurgitation, severe tricuspid regurgitation was independently associated with a higher risk of all-cause mortality (adjusted hazard ratio 1.38, 95% confidence interval 1.01-1.88, P  = 0.042), whereas moderate tricuspid regurgitation did not.

CONCLUSION

In a contemporary, real-world cohort of patients with advanced heart failure, several clinical and echocardiographic characteristics are associated with an increased likelihood of severe tricuspid regurgitation. Patients with severe tricuspid regurgitation have an increased risk of mortality.

Running on empty: Factors underpinning impaired cardiac output reserve in heart failure with preserved ejection fraction

Heart failure with preserved ejection fraction (HFpEF) is frequently attributed etiologically to an underlying left ventricular (LV) diastolic dysfunction, although its pathophysiology is far more complex and can exhibit significant variations among patients. This review endeavours to systematically unravel the pathophysiological heterogeneity by illustrating diverse mechanisms leading to an impaired cardiac output reserve, a central and prevalent haemodynamic abnormality in HFpEF patients. Drawing on previously published findings from our research group, we propose a pathophysiology-guided phenotyping based on the presence of: (1) LV diastolic dysfunction, (2) LV systolic pathologies, (3) arterial stiffness, (4) atrial impairment, (5) right ventricular dysfunction, (6) tricuspid valve regurgitation, and (7) chronotopic incompetence. Tailored to each specific phenotype, we explore various potential treatment options such as antifibrotic medication, diuretics, renal denervation and more. Our conclusion underscores the pivotal role of cardiac output reserve as a key haemodynamic abnormality in HFpEF, emphasizing that by phenotyping patients according to its individual pathomechanisms, insights into personalized therapeutic approaches can be gleaned.

Applying the TRILUMINATE Eligibility Criteria to Real-World Patients Receiving Tricuspid Valve Transcatheter Edge-to-Edge Repair

BACKGROUND

According to the TRILUMINATE (Clinical Trial to Evaluate Cardiovascular Outcomes in Patients Treated With the Tricuspid Valve Repair System) trial, transcatheter tricuspid edge-to-edge repair (T-TEER) improves quality of life beyond medical treatment, while no effects on heart failure hospitalization (HFH) and survival were observed at 1 year. However, the generalizability of the TRILUMINATE trial to real-world conditions remains a subject of discussion.

OBJECTIVES

The aim of this study was to apply the clinical TRILUMINATE inclusion and exclusion criteria to a real-world T-TEER patient group and evaluate symptomatic and survival outcome in TRILUMINATE-eligible and TRILUMINATE-ineligible patients.

METHODS

Clinical TRILUMINATE inclusion and exclusion criteria were applied to a cohort of patients who underwent T-TEER at 5 European centers from 2016 to 2022. Study patients were compared regarding baseline characteristics, survival, HFH, and symptomatic outcomes as measured by NYHA functional class, a quality-of-life questionnaire and 6-minute walk distance.

RESULTS

Of 962 patients, 54.8% were classified as TRILUMINATE eligible, presenting with superior left ventricular function and fewer comorbidities compared with the ineligible population. Tricuspid regurgitation reduction, improvement in NYHA functional class, quality of life, and exercise capacity were comparable in both groups. However, the 1-year survival and HFH rates significantly differed (tricuspid regurgitation ≤2+ at discharge, 82% vs 85%; survival, 85% vs 75%; HFH, 14% vs 22% for eligible vs ineligible patients).

CONCLUSIONS

The observed differences in survival and HFH outcomes suggest a limited generalizability of TRILUMINATE to real-world conditions and indicate the need for additional studies evaluating the outcomes after T-TEER in less selected patient populations.

Right ventricle assessment before tricuspid valve interventions

In the latest ESC/EACTS Guidelines for the Management of Valvular Heart Disease, right ventricular dilatation and dysfunction, severe pulmonary hypertension and tricuspid annulus dilatation were reported to be the most important parameters to consider in patient selection for tricuspid valve interventions. Indeed, comprehensive right ventricular assessment is crucial in patients with severe tricuspid regurgitation who may benefit from transcatheter or surgical procedures. However, the only guideline parameter considered for intervention has been tricuspid annular dilatation in the presence of at least mild to moderate tricuspid regurgitation, with no other right ventricular markers used in the decision-making process for invasive treatment. Notably, challenges in the assessment of right ventricular function may limit establishing thresholds for defining right ventricular dysfunction. The aim of this review is to summarize current evidence on the prognostic significance of right ventricular function in patients with tricuspid regurgitation undergoing percutaneous or surgical interventions.

New severity criteria for tricuspid regurgitation in a broad population of "real life" patients: Prevalence and prognostic impact

Introduction Our objective was to determine, in "real life" patients, the prevalence of massive and torrential regurgitation among patients diagnosed with severe tricuspid regurgitation (TR), as well as its impact on long-term prognosis. Methods In a single-center retrospective study, all patients with an echocardiographic diagnosis of severe TR attended at a tertiary care hospital of an European country from January 2008 to December 2017 were recruited. Images were analysed off-line to measure the maximum vena contracta (VC) and TR was classified into three groups: severe (VC ≥ 7 mm), massive (VC 14-20 mm), and torrential (VC ≥ 21 mm). The impact of this classification on the combined event of heart failure (HF) admission and all-cause death in follow-up was investigated. Results A total of 614 patients (70 ± 13 years, 72 % women) were included. 81.4 % had severe TR, 15.8 % massive TR, and 2.8 % torrential TR. The 5-year HF-free survival  was 42 %, 43 %, and 12 % (p = 0.001), for the different subgroups of severe TR, respectively. After adjusting for baseline characteristics, TR severity was an independent predictor of survival free of the combined end-point: HR 0.91 [95 % CI 0.70-1.18] p = 0.46, for massive TR; and HR 2.5 [95 % CI 1.49-4.21] p = 0.001, for torrential TR considering severe TR as reference. Conclusions The prevalence of massive and torrential TR is not negligible among patients with severe TR in real life. The prognosis is significantly worse for patients with torrential TR measured by the maximum VC.

Outpatient tricuspid regurgitation in the community: Clinical context and outcome

BACKGROUND AND AIMS

Epidemiology of tricuspid regurgitation (TR) is poorly known and its burden in the community is challenging to define. We aimed to evaluate the prevalence of TR in a geographically defined area and its outcome, in particular overall survival and hospitalization, considering different clinical contexts.

METHODS

We retrospectively analyzed consecutive outpatients referred between 2006 and 2013 for echocardiography and clinical evaluation. Patients with at least moderate TR were included and five different clinical settings were defined: concomitant significant left-sided valvular heart disease (LVHD-TR), heart failure (HF-TR), previous open-heart valvular surgery (postop-TR), pulmonary hypertension (PHTN-TR) and isolated TR (isolated-TR). Primary endpoint was a composite outcome of all-cause mortality or first hospitalization for HF.

RESULTS

Of 6797 consecutive patients with a clinical visit and echocardiograms performed in routine practice in a geographically defined community, moderate or severe TR was found in 4.8% of patients (327) . During median follow-up of 6.1 years, TR severity was a determinant of event-free survival. Analyzed for each clinical subset, eight-year event-free survival was 87 ± 7% for postop-TR subgroup, 75 ± 7% for isolated-TR, 67 ± 6% for PHTN-TR, 58 ± 6% for LHVD -TR and 52 ± 11% for HF-TR.

CONCLUSION

Moderate or more TR is a notable finding in the community and has impact on event-free survival in all clinical settings, with the worst outcomes when associated with relevant left-sided valvular heart disease and HF.

Contemporary Approach to Tricuspid Regurgitation: Knowns, Unknowns, and Future Challenges

Severe tricuspid regurgitation (TR) worsens heart failure and is associated with impaired survival. In daily clinical practice, patients are referred late, and tricuspid valve interventions (surgical or transcatheter) are underutilised, which may lead to irreversible right ventricular damage and increases risk. This article addresses the appropriate timing and modality for an intervention (surgical or transcatheter), and its potential benefits on clinical outcomes. Ongoing randomised controlled trials will provide further insights into the efficacy of transcatheter valve interventions compared with medical treatment.

Epidemiology, pathophysiology, diagnosis and management of chronic right-sided heart failure and tricuspid regurgitation. A clinical consensus statement of the Heart Failure Association (HFA) and the European Association of Percutaneous Cardiovascular Interventions (EAPCI) of the ESC

Right-sided heart failure and tricuspid regurgitation are common and strongly associated with poor quality of life and an increased risk of heart failure hospitalizations and death. While medical therapy for right-sided heart failure is limited, treatment options for tricuspid regurgitation include surgery and, based on recent developments, several transcatheter interventions. However, the patients who might benefit from tricuspid valve interventions are yet unknown, as is the ideal time for these treatments given the paucity of clinical evidence. In this context, it is crucial to elucidate aetiology and pathophysiological mechanisms leading to right-sided heart failure and tricuspid regurgitation in order to recognize when tricuspid regurgitation is a mere bystander and when it can cause or contribute to heart failure progression. Notably, early identification of right heart failure and tricuspid regurgitation may be crucial and optimal management requires knowledge about the different mechanisms and causes, clinical course and presentation, as well as possible treatment options. The aim of this clinical consensus statement is to summarize current knowledge about epidemiology, pathophysiology and treatment of tricuspid regurgitation in right-sided heart failure providing practical suggestions for patient identification and management.

Understanding Treatment Preferences for Patients with Tricuspid Regurgitation

Background. Tricuspid regurgitation (TR) is a high-prevalence disease associated with poor quality of life and mortality. This quantitative patient preference study aims to identify TR patients' perspectives on risk-benefit tradeoffs. Methods. A discrete-choice experiment was developed to explore TR treatment risk-benefit tradeoffs. Attributes (levels) tested were treatment (procedure, medical management), reintervention risk (0%, 1%, 5%, 10%), medications over 2 y (none, reduce, same, increase), shortness of breath (none/mild, moderate, severe), and swelling (never, 3× per week, daily). A mixed logit regression model estimated preferences and calculated predicted probabilities. Relative attribute importance was calculated. Subgroup analyses were performed. Results. An online survey was completed by 150 TR patients. Shortness of breath was the most important attribute and accounted for 65.8% of treatment decision making. The average patients' predicted probability of preferring a "procedure-like" profile over a "medical management-like" profile was 99.7%. This decreased to 78.9% for a level change from severe to moderate in shortness of breath in the "medical management-like" profile. Subgroup analysis confirmed that patients older than 64 y had a stronger preference to avoid severe shortness of breath compared with younger patients (P < 0.02), as did severe or worse TR patients relative to moderate. New York Heart Association class I/II patients more strongly preferred to avoid procedural reintervention risk relative to class III/IV patients (P < 0.03). Conclusion. TR patients are willing to accept higher procedural reintervention risk if shortness of breath is alleviated. This risk tolerance is higher for older and more symptomatic patients. These results emphasize the appropriateness of developing TR therapies and the importance of addressing symptom burden.

Highlights

This study provides quantitative patient preference data from clinically confirmed tricuspid regurgitation (TR) patients to understand their treatment preferences.Using a targeted literature search and patient, physician, and Food and Drug Administration feedback, a cross-sectional survey with a discrete-choice experiment that focused on 5 of the most important attributes to TR patients was developed and administered online.TR patients are willing to accept higher procedural reintervention risk if shortness of breath is alleviated, and this risk tolerance is higher for older and more symptomatic patients.

Transthoracic and transoesophageal echocardiography for tricuspid transcatheter edge-to-edge repair: a step-by-step protocol

Tricuspid regurgitation (TR) carries an unfavourable prognosis and often leads to progressive right ventricular (RV) failure. Secondary TR accounts for over 90% of cases and is caused by RV and/or tricuspid annulus dilation, in the setting of left heart disease or pulmonary hypertension. Surgical treatment for isolated TR entails a high operative risk and is seldom performed. Recently, transcatheter edge-to-edge repair (TEER) has emerged as a low-risk alternative treatment in selected patients. Although the experience gained from mitral TEER has paved the way for the technique's adaptation to the tricuspid valve (TV), its anatomical complexity necessitates precise imaging. To this end, a comprehensive protocol integrating 2D and 3D imaging from both transthoracic echocardiography (TTE) and transoesophageal echocardiography (TOE) plays a crucial role. TTE allows for an initial morphological assessment of the TV, quantification of TR severity, evaluation of biventricular function, and non-invasive haemodynamic evaluation of pulmonary circulation. TOE, conversely, provides a detailed evaluation of TV morphology, enabling precise assessment of TR mechanism and severity, and represents the primary method for determining eligibility for TEER. Once a patient is considered eligible for TEER, TOE, alongside fluoroscopy, will guide the procedure in the catheterization lab. High-quality TOE imaging is crucial for patient selection and to achieve procedural success. The present review examines the roles of TTE and TOE in managing patients with severe TR eligible for TEER, proposing the step-by-step protocol successfully adopted in our centre.

[Pulmonary heart: A review]

The review on the problem of the pulmonary heart pursues two goals: firstly, to restore historical justice and to show the priority studies of doctor Dmitry D. Pletnev on such problems as diagnosis of right ventricular myocardial infarction, clinical characteristics of congestive heart failure of the right ventricle; secondly, to outline the modern concept of the pulmonary heart. The review provides an analysis of the pathogenetic mechanisms of the development of heart failure in the pulmonary heart. Much attention is paid to echo cardiography data and biological markers are emphasized in assessing the function of the right atrium, right ventricle, tricuspid valve regurgitation, pulmonary artery pressure. Prognostically unfavorable signs of the course of the pulmonary heart have been identified, which include a high degree of tricuspid valve regurgitation, the amplitude of movement of the fibrous valve ring (TAPSE) and atrial fibrillation developing with dilation of the right atrium.

[T-TEER: description of a development process]

Tricuspid valve regurgitation (TR) is becoming increasingly more clinically important. While considered as an accompanying symptom of left heart pathologies in the past, TR is now seen as an independent and clinically significant condition. TR can lead to volume overload of the right ventricle, resulting in dilatation of the tricuspid valve annulus and worsening of the regurgitation. Undetected or untreated severe TR can lead to recurrent cardiac decompensation with hospitalization, reduced quality of life and death. Previous treatment options were limited to cardiac surgery and associated with high complication and mortality rates, especially in isolated TR. Therefore, many patients are considered inoperable so that the new interventional treatment measures nowadays often represent the only treatment option. Interventional treatment options such as the edge-to-edge procedure (T-TEER) with TriClip™ or the PASCAL™ system are very safe interventions that have already shown promising results, including reduction of TR, improvement in heart failure symptoms and the quality of life. The influence on the mortality and the necessity for hospitalization due to heart failure are currently being investigated in several randomized studies. Patient selection and timing of the intervention are crucial. Cardiovascular imaging plays a decisive role in selecting the appropriate method and timing of the intervention. The prognosis depends on factors, such as the severity of TR, right ventricular dysfunction, and pulmonary arterial hypertension. Overall, interventional TR treatment is a promising advancement in treatment from which many patients can benefit in the future.