Canadian Journal of Cardiology

Transcatheter Tricuspid Valve Repair in Prohibitive Risk Patients: Impact on Quality of Life and Major Organ Systems

Published:September 09, 2022DOI:



      Percutaneous repair for severe tricuspid regurgitation (TR) is emerging as a viable option, but patient selection is challenging and predetermined by comorbidities. This study evaluated mid-term outcomes of transcatheter tricuspid valve repair (TTVR) in very sick inoperable patients, and explored the concept of risk-based therapeutic futility.


      TTVR patients treated in our center were prospectively assigned to prohibitive (PR) and high-risk (HR) subgroups, based on Society of Thoracic Surgeons (STS) Score, frailty indices, and major organ system compromise. Efficacy and safety outcomes were compared at baseline, 30 days and 6 months.


      Thirty-three patients (mean-age 81.9±5.1) completed follow-up between May 2021 and March 2022, 18 PR (mean STS-Score 15.5±7%) and 15 HR (mean STS-Score 6.4±1.7%). The primary efficacy endpoint of at least one-grade TR reduction by 30 days was recorded in 93.9% of all patients, with no device related adverse events. Improvement in initial New York Heart Association class III/IV occurred in 74% of PR and 93% of HR patients. Six-minute walk test increased by 81±43.6meters (p<0.001) and 85.8±47.9meters (p<0.001), respectively. Renal function tests improved by 15% (p=0.048) vs 7% (p=0.050), while liver enzymes decreased by 18% (p=0.020) vs 28% (p=0.052). Right ventricular systolic function likewise increased in both subgroups by at least 24% (p<0.001). Six-month mortality was 12.1%, with 6 hospitalizations for acute heart failure.


      TR reduction significantly impacted quality of life, functional capacity, cardiac remodeling and multiorgan involvement, similarly in PR and HR patients. TTVR is feasible in very sick symptomatic patients, irrespective of predicted risk.

      Graphical abstract

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        • Singh J.P.
        • Evans J.C.
        • Levy D.
        • et al.
        Prevalence and clinical determinants of mitral, tricuspid, and aortic regurgitation (the Framingham Heart Study).
        Am J Cardiol. 1999; 83: 897-902
        • Asmarats L.
        • Taramasso M.
        • Rodés-Cabau J.
        Tricuspid valve disease: diagnosis, prognosis and management of a rapidly evolving field.
        Nat Rev Cardiol. 2019; 16: 538-554
      1. Otto CM, Nishimura RA, Bonow RO, et al. 2020 ACC/AHA Guideline for the Management of Patients With Valvular Heart Disease. Circulation. 2021. 2;143(5):e35-e71.

        • Vahanian A.
        • Beyersdorf F.
        • Praz F.
        • et al.
        ESC/EACTS Guidelines for the management of valvular heart disease.
        Eur Heart J. 2021; 28: ehab395
        • Kawsara A.
        • Alqahtani F.
        • Nkomo V.T.
        • et al.
        Determinants of Morbidity and Mortality Associated With Isolated Tricuspid Valve Surgery.
        Journal of the American Heart Association. 2021; 10e018417
        • Zack C.J.
        • Fender E.A.
        • Chandrashekar P.
        • et al.
        National Trends and Outcomes in Isolated Tricuspid Valve Surgery.
        J Am Coll Cardiol. 2017; 24: 2953-2960
        • Taramasso M.
        • Alessandrini H.
        • Latib A.
        • et al.
        Outcomes After Current Transcatheter Tricuspid Valve Intervention: Mid-Term Results From the International TriValve Registry.
        J Am Coll Cardiol Intv. 2019; 12: 155-165
        • Nickenig G.
        • Weber M.
        • Lurz P.
        • et al.
        Transcatheter Edge-to-Edge Repair for Reduction of Tricuspid Regurgitation: 6-Month Outcomes of the TRILUMINATE Single-Arm Study.
        Lancet. 2019; 394: 2002-2011
        • Lurz P.
        • Stephan von Bardeleben S.
        • Weber M.
        • et al.
        Transcatheter Edge-to-Edge Repair for Treatment of Tricuspid Regurgitation.
        J Am Coll Cardiol. 2021; 77: 229-239
        • Kim Y.J.
        • Kwon D.A.
        • Kim H.K.
        • et al.
        Determinants of surgical outcome in patients with isolated tricuspid regurgitation.
        Circulation. 2009; 120: 1672-1678
        • LaPar D.J.
        • Likosky D.S.
        • Zhang M.
        • et al.
        Development of a Risk Prediction Model and Clinical Risk Score for Isolated Tricuspid Valve Surgery.
        Ann Thorac Surg. 2018; 106: 129-137
        • Lang R.M.
        • Badano L.P.
        • Mor-Avi V.
        • et al.
        Recommendations for cardiac chamber quantification by echocardiography in adults: an update from the American Society of Echocardiography and the European Association of Cardiovascular Imaging.
        J Am Soc Echocardiogr. 2015; 28: 1-39
        • Hahn R.T.
        • Thomas J.D.
        • Khalique O.K.
        • et al.
        Imaging Assessment of Tricuspid Regurgitation Severity.
        JACC Cardiovasc Imaging. 2019; 12: 469-490
        • Hahn R.T.
        • Zamorano J.L.
        The need for a new tricuspid regurgitation grading scheme.
        Eur Heart J Cardiovasc Imaging. 2017; 18: 1342-1343
        • Stone G.W.
        • Adams D.H.
        • Kappetein A.P.
        • et al.
        Clinical Trial Design Principles and Endpoint Definitions for Transcatheter Mitral Valve Repair and Replacement: Part 2: Endpoint Definitions: A Consensus Document from the Mitral Valve Academic Research Consortium.
        J Am Coll Cardiol. 2015; 66: 308-321
      2. Kalbacher D, Schäfer U, von Bardeleben RS, et al. Impact of tricuspid valve regurgitation in surgical high-risk patients undergoing MitraClip implantation: results from the TRAMI registry. EuroIntervention, 2017. 3;12(15):1809-1816.

      3. Hausleiter J, Braun D, Orban M, et al. Patient selection, echocardiographic screening and treatment strategies for interventional tricuspid repair using the edge-to-edge repair technique. EuroIntervention. 2018. 20;14(6):645-653.

      4. Lurz P, Orban M, Besler C, et al. Clinical characteristics, diagnosis, and risk stratification of pulmonary hypertension in severe tricuspid regurgitation and implications for transcatheter tricuspid valve repair. Eur Heart J. 2020. 1;41(29):2785-2795.

        • Muntané-Carol G.
        • Taramasso M.
        • Miura M.
        • et al.
        Transcatheter Tricuspid Valve Intervention in Patients With Right Ventricular Dysfunction or Pulmonary Hypertension: Insights From the TriValve Registry.
        Circ Cardiovasc Interv. 2021; 14e009685
      5. Besler C, Orban M, Rommel KP, et al. Predictors of Procedural and Clinical Outcomes in Patients with Symptomatic Tricuspid Regurgitation Undergoing Transcatheter Edge-to-Edge Repair. J Am Coll Cardiol Intv., 2018. 25;11(12):1119-1128.

      6. Sugiura A, Tanaka T, Kavsur R, et al. Leaflet Configuration and Residual Tricuspid Regurgitation After Transcatheter Edge-to-Edge Tricuspid Repair. J Am Coll Cardiol Intv., 2021. 25;14(20):2260-2270.

        • Meijerink F.
        • Koch K.T.
        • de Winter R.J.
        • et al.
        Transcatheter tricuspid valve repair: early experience in the Netherlands.
        Neth Heart J. 2021; 29: 595-603
      7. Karam N, Braun D, Mehr M, et al. Impact of Transcatheter Tricuspid Valve Repair for Severe Tricuspid Regurgitation on Kidney and Liver Function. J Am Coll Cardiol Intv., 2019. 12;12(15):1413-1420.

      8. Tanaka T, Kavsur R, Sugiura A, et al. Prognostic impact of hepatorenal function in patients undergoing transcatheter tricuspid valve repair. Nature Sci Rep., 2021. 13;11(1):14420.

      9. Ancona F, Melillo F, Calvo F, et al. Right ventricular systolic function in severe tricuspid regurgitation: prognostic relevance of longitudinal strain. Eur Heart J Cardiovasc Imaging, 2021. 20;22(8):868-875.