# Patient Selection for Transcatheter Tricuspid Valve Intervention: Not Too Early, Not Too Late

## TL;DR

This paper discusses how to best select patients for transcatheter tricuspid valve treatments, emphasizing the importance of timing and using advanced imaging to guide decisions.

## Contribution

The paper introduces a stage-based framework for patient selection and device choice in tricuspid regurgitation, integrating multimodal imaging and risk scores.

## Key findings

- Early referral before advanced right heart failure improves clinical outcomes in tricuspid regurgitation.
- Multimodal imaging and risk scores are essential for selecting between repair and replacement therapies.
- Emerging devices like orthotopic and heterotopic valves offer new options for complex cases.

## Abstract

Tricuspid regurgitation (TR) is a common but frequently underrecognized condition associated with substantial morbidity and mortality. Long regarded as a mere bystander of left-sided heart disease, TR was often left untreated, contributing to late referrals and poor surgical outcomes. The emergence of transcatheter tricuspid valve interventions has broadened therapeutic options, particularly for high-risk or inoperable patients. However, procedural success and clinical benefit critically depend on appropriate patient selection and timely intervention. This review outlines the evolving landscape of TR management, emphasizing the importance of anatomical and clinical stage-adapted device selection. Key determinants of feasibility and prognosis include right ventricular function and dimensions, TR severity, tricuspid valve leaflet and annular remodeling, and hemodynamic congestion. Advanced imaging modalities and invasive hemodynamics provide incremental value for risk stratification. While tricuspid valve transcatheter edge-to-edge repair (T-TEER) and orthotopic valve replacement are the most widely adopted techniques, direct annuloplasty, heterotopic valve replacement, and coaptation enhancement devices may be more appropriate in anatomically advanced stages. Despite symptomatic improvement and reduced heart failure hospitalizations across different treatment modalities, a survival benefit has yet to be demonstrated. Delayed referral remains a challenge, often precluding repair or even replacement strategies. Dedicated risk models may improve prognostication and guide procedural decision-making. Ultimately, a multidisciplinary approach incorporating multiparametric assessment is essential to identify optimal candidates, guide timing, and personalize therapy. Ongoing trials and long-term outcome data are needed to refine treatment algorithms and clarify the role of early intervention in altering the natural course of severe TR.

Stage-based stratification and device selection in tricuspid regurgitation. Echocardiographic and clinical markers across progressive stages of tricuspid regurgitation guide the choice between transcatheter tricuspid valve repair and replacement. Optimal medical therapy remains essential at all stages. Repair, currently limited to edge-to-edge repair, is often suitable in earlier stages, while orthotopic replacement may also be appropriate depending on anatomical feasibility (left panel). With progressing disease, both repair and orthotopic replacement remain potential options when anatomical requirements are met (middle panel). In very advanced disease stages, neither repair nor orthotopic replacement may be feasible, warranting consideration of heterotopic and coaptation enhancement devices. The illustration is intended as a conceptual framework rather than a definitive treatment algorithm, and device choice should always be individualized. Abbreviations: NYHA, New York Heart Association; RA, right atrium; RV, right ventricle; TR, tricuspid regurgitation.

•Transcatheter therapies have transformed the management of severe tricuspid regurgitation, yet clinical benefit depends critically on early referral before the onset of advanced right heart failure.•Integration of multimodality imaging, hemodynamics, and clinical risk scores is essential for optimal patient selection and for tailoring the choice between repair and replacement across the disease spectrum.•Emerging technologies, including orthotopic and heterotopic valve replacement and coaptation enhancement devices, expand treatment options for anatomically complex patients, but long-term durability, predictors of reverse remodeling, and the role of early intervention remain key areas for future investigation.

Transcatheter therapies have transformed the management of severe tricuspid regurgitation, yet clinical benefit depends critically on early referral before the onset of advanced right heart failure.

Integration of multimodality imaging, hemodynamics, and clinical risk scores is essential for optimal patient selection and for tailoring the choice between repair and replacement across the disease spectrum.

Emerging technologies, including orthotopic and heterotopic valve replacement and coaptation enhancement devices, expand treatment options for anatomically complex patients, but long-term durability, predictors of reverse remodeling, and the role of early intervention remain key areas for future investigation.