Heart Valve Centre Approach to Severe Tricuspid Regurgitation: Real-World Data and Outcomes

Abstract

Background: Severe tricuspid regurgitation (TR) is associated with significant morbidity and mortality but remains markedly undertreated. Optimal management strategies and the timing of intervention are still unclear.

Methods: We retrospectively analysed 476 patients with isolated symptomatic severe TR treated at our heart valve centre from 2018 to 2023. Patients were categorised into 3 groups: conservative management (n = 323), surgery (n = 76), and transcatheter edge-to-edge repair (T-TEER) (n = 77). Risk stratification was performed using the TRI-SCORE, classifying patients into low/intermediate (< 6) and high (≥ 6) risk categories. The primary end point was a composite of all-cause mortality and heart failure hospitalisation.

Results: Over 20 ± 7 months of follow-up, the primary end point occurred in 35.8% of patients in the conservative group, 19.7% in the surgical group, and 18.2% in the T-TEER group. Stratification by TRI-SCORE revealed 349 patients (73%) in the low/intermediate risk category, of whom 46 (13%) underwent T-TEER, 63 (18%) surgery, and 240 (69%) conservative management; and 127 patients (27%) in the high risk category, of whom 32 (25%) underwent T-TEER, 13 (10%) surgery, and 82 (65%) conservative management. Both surgery (hazard ratio [HR] 0.49, 95% confidence interval [CI] 0.28-0.84; P = 0.01) and T-TEER (HR 0.50, 95% CI 0.29-0.88; P = 0.02) were associated with a significantly lower incidence of the primary end point compared with conservative management. In low/intermediate risk patients, invasive treatments (surgery or T-TEER) significantly reduced the primary end point, whereas no significant benefit was observed in high risk patients. Multivariable regression analysis identified high TRI-SCORE (adjusted HR 2.32, 95% CI 1.66-3.26; P = 0.03) and conservative management (adjusted HR 2.66, 95% CI 1.70-4.16; P < 0.01) as the only predictors of the primary end point.

Conclusions: In patients with symptomatic severe TR managed through a modern heart valve centre approach, invasive treatments (surgery or T-TEER) may provide a prognostic benefit over conservative management, particularly in early disease stages (TRI-SCORE < 6).

Keywords: TRI-SCORE; heart valve centre; medical therapy; transcatheter edge-to-edge repair; transcatheter tricuspid intervention; tricuspid surgery.