INTRODUCTION:The impact of coexisting left-sided valvular heart disease (VHD) on clinical outcomes following tricuspid valve edge-to-edge repair (T-TEER) for tricuspid regurgitation (TR) remains unclear, particularly under real-world conditions. To evaluate the prevalence and prognostic impact of concomitant left-sided VHD in patients undergoing T-TEER. METHODS:This study included all patients undergoing T-TEER from the European Registry of Transcatheter Repair for Tricuspid Regurgitation (EuroTR; NCT06307262) with complete echocardiographic data on left-sided valve disease. Study endpoints included survival and heart failure hospitalizations (HFH) at 2 years, NYHA functional class, and TR reduction. RESULTS:Among a total of 1647 eligible patients, 95.8%, 35.6%, and 3.8% had ≥mild, moderate, and severe concomitant VHD, respectively. Moderate or higher VHD was associated with a significantly reduced 2-year survival (P < .001) and reduced 2-year HFH-free survival (P = .005). Multivariate regression analysis confirmed ≥ moderate VHD to be an independent predictor of mortality (hazard ratio 1.54, 95% CI 1.21-1.96, P < .001). Despite worse TR and NYHA functional class at baseline in patients with ≥moderate VHD, T-TEER was associated with a significant TR reduction (P < .001) and symptomatic improvement (P < .001). CONCLUSION:Concomitant left-sided VHD is common among patients undergoing T-TEER and is independently associated with worse survival and higher rates of HFH. Nevertheless, T-TEER provides meaningful symptomatic benefit and durable TR reduction in patients with and without VHD burden.

AIMS:The GLIDE Score (septolateral gap, predominant jet location, image quality, chordal structure density, and en-face jet morphology) may predict successful tricuspid transcatheter edge-to-edge repair. This study aimed to evaluate its predictive value in transcatheter tricuspid valve annuloplasty (TTVA). METHODS AND RESULTS:This study was performed on 204 consecutive patients who underwent TTVA between 2018 and 2023 at two tertiary German centres. The GLIDE Score was assessed using preprocedural transoesophageal echocardiograms.Residual tricuspid regurgitation (TR) grade ≤ I was achieved in 44.6% of cases; 83.7% had a TR reduction of ≥2 grades and 72.8% a residual TR grade ≤ II. Lower GLIDE Scores were significantly associated with higher rates of residual TR ≤ I, residual TR ≤ II (P < 0.001), and TR reduction of ≥2 grades (P = 0.001). Residual TR ≤ I was achieved in 79% of patients with a score of 0-1, compared to 19% with scores of ≥4. After adjustment for baseline TR grade, the GLIDE Score was still independently associated with procedural outcomes. In this TTVA cohort, a modified GLIDE Score, excluding chordal structure density and including anteroseptal and bicommissural annular diameters, demonstrated strong predictive performance, with an area under the curve of 0.84 [original GLIDE Score 0.79 (95% CI: 0.72-0.85)] in the main cohort and 0.76 in an external validation cohort (n = 86). CONCLUSION:The GLIDE Score reliably identifies patients with a high likelihood of achieving procedural success after TTVA. Incorporating annular diameters may further improve predictive accuracy and guide treatment selection in patients undergoing transcatheter tricuspid valve repair.

Background and Aims The coexistence of moderate mitral regurgitation (MR) and severe tricuspid regurgitation (TR) is common, yet evidence guiding optimal management remains limited. Transcatheter edge-to-edge repair (TEER) of both valves-performed either sequentially or in combination-has emerged as a potential therapeutic strategy. This study aimed to assess the prognostic impact of moderate MR in patients undergoing tricuspid TEER (T-TEER) for severe TR and to evaluate whether concomitant mitral TEER (M-TEER) improves clinical outcomes. Methods Data from the EuroTR registry (2016-25) were analysed, including patients with severe TR treated with T-TEER. Outcomes were compared between patients with untreated moderate MR and those who underwent concomitant M-TEER using propensity score matching (PSM). The primary endpoint was all-cause mortality at 2 years. Secondary endpoints included New York Heart Association (NYHA) class, 6 min walk distance (6MWD), TR severity, and heart failure rehospitalizations. Results Among 3100 patients, 30% had moderate MR, which was associated with higher 2-year mortality (23% vs 37%, p<0.0001). After PSM, 217 matched patients treated with concomitant M-TEER had greater TR reduction (-1.9 vs -1.6 grades, P = .001), better NYHA improvement, and increased 6MWD at follow-up. Survival was higher in the combined treatment group (87% vs 76% at 1 year; 81% vs 70% at 2 years, P = .005). In a multivariable analysis, moderate MR predicted increased mortality [hazard ratio (HR) 1.81, P = .005), while combined M-TEER predicted better survival (HR 0.46, P < .0001). Conclusions Moderate MR predicts impaired prognosis in patients undergoing T-TEER for treatment of severe TR. Concomitant M-TEER is associated with improved survival and functional outcomes in this population with multivalve disease. These findings are hypothesis-generating and need to be tested in a dedicated randomized controlled trial.

AIMS:Tricuspid regurgitation (TR) frequently coexists with left-sided heart failure (HF). Tricuspid valve transcatheter edge-to-edge repair (T-TEER) has emerged as a treatment for severe TR, yet the prognostic role of coexisting HF phenotypes remains unclear. METHODS AND RESULTS:In the EuroTR registry, we assessed the impact of HF subtypes on 2-year all-cause mortality after T-TEER. Patients were stratified by left ventricular ejection fraction (LVEF) into reduced/mildly reduced (HFmrEF/HFrEF <50%) and preserved (≥50%). Those with preserved LVEF were further divided by pulmonary capillary wedge pressure (PCWP) into HFpEF (>15 mmHg) and non-overt left-sided HF (≤15 mmHg). Among 1,773 patients, 30% had HFmrEF/HFrEF, 44% HFpEF, and 26% non-overt left-sided HF. Procedural success (TR ≤moderate) was highest in non-overt left-sided HF (87%) and lowest in HFmrEF/HFrEF (78%). Symptom burden improved across all groups (p<0.001). Estimated 2-year mortality was 25.0% in HFmrEF/HFrEF, 20.3% in HFpEF, and 13.1% in non-overt left-sided HF. Procedural success was associated with improved outcomes in all groups (p<0.01). Among successfully treated patients, survival was comparable between HFmrEF/HFrEF and HFpEF at 1-year but better in HFpEF at 2-years (p=0.027). Predictors of survival differed by phenotype: right ventricular function for HFmrEF/HFrEF, right-sided pressures for HFpEF, and baseline TR severity for non-overt left-sided HF. CONCLUSION:Consideration of left-sided pathologies in patients with significant TR is important as outcomes and predictors for survival differ. Across HF phenotypes, procedural success is associated with survival but the prognostic impact of TR reduction may unfold over time especially in HFpEF.

Data on the association of previous cardiac surgery (PCS) with outcomes following tricuspid valve transcatheter edge-to-edge repair (T-TEER) are limited. This study aimed to evaluate the impact of PCS on outcomes after T-TEER. This analysis included patients from the EuroTR registry (European Registry of Transcatheter Repair for Tricuspid Regurgitation; NCT0630726) who underwent T-TEER for clinically relevant tricuspid regurgitation (TR) between 2016 and 2024 and had available information on cardiac surgical history. Study endpoints were procedural TR reduction, improvement in NYHA functional class, all-cause mortality, and the composite of death or heart failure hospitalization (HFH) at 2 years. Among 2929 patients, 27.2

BACKGROUND:N-terminal pro-B-type natriuretic peptide (NT-proBNP) is an established marker of myocardial stress, yet its prognostic role in tricuspid valve transcatheter edge-to-edge repair (T-TEER) for tricuspid regurgitation (TR) remains unclear. OBJECTIVES:The aim of this study was to evaluate the prognostic value of baseline NT-proBNP and its early postprocedural trajectory after T-TEER. METHODS:Patients undergoing T-TEER with available baseline NT-proBNP measurements in the EuroTR (European Registry of Transcatheter Repair for Tricuspid Regurgitation) registry were analyzed. NT-proBNP was evaluated continuously and by tertiles, with longitudinal changes assessed when serial measurements were available. Endpoints were the 2-year composite of all-cause mortality or first heart failure hospitalization, changes in NT-proBNP, symptomatic alleviation, and residual TR. RESULTS:In total, 2,282 patients (median age 80 years [Q1-Q3: 76-83 years], 54% women, 86% in NYHA functional class III or IV) with baseline NT-proBNP values (tertile 1, ≤1,674 pg/mL; tertile 2, 1,674-3,743 pg/mL; and tertile 3, >3,743 pg/mL) were included. Higher tertiles were associated with greater comorbidity burden, more advanced biventricular remodeling, and more severe TR. Baseline NT-proBNP was independently associated with the primary endpoint (adjusted HR: 1.62; 95% CI: 1.29-2.04). Residual TR ≤2+ at discharge occurred in 86.3%, 82.9%, and 81.4% across tertiles (P = 0.040), and higher NT-proBNP was associated with a lower likelihood of symptomatic alleviation (adjusted OR per log10 increase: 0.63; 95% CI: 0.48-0.84; P < 0.001). Both baseline NT-proBNP and higher than expected 30-day levels relative to baseline were independently associated with higher subsequent risk for the primary endpoint. CONCLUSIONS:Baseline NT-proBNP was independently associated with 2-year mortality or heart failure hospitalization after T-TEER. Early postprocedural NT-proBNP trajectories provided incremental prognostic information and may identify patients at increased risk.

Background According to the 2025 ESC/EACTS guidelines for the management of valvular heart disease, transcatheter tricuspid valve interventions (TTVI) have received a Class IIa recommendation (Level of Evidence: A) for the treatment of patients with severe symptomatic tricuspid regurgitation. However, in patients with severe left ventricular dysfunction (LVD) or right ventricular dysfunction (RVD) or precapillary pulmonary hypertension (pcPH), optimal medical therapy (OMT) is preferred because of the potential risk for futility. Objectives The aim of this study was to evaluate clinical and symptomatic outcomes in such “OMT candidate” patients. Methods Using data from EuroTR (European Registry of Transcatheter Repair for Tricuspid Regurgitation), guideline-based thresholds for LVD, RVD, and pcPH were applied to patients undergoing tricuspid valve transcatheter edge-to-edge repair (T-TEER). Patients meeting ≥1 exclusion criterion (“OMT candidates”) were compared with those meeting current recommendations (“TTVI appropriate”) regarding NYHA functional class improvement and 2-year survival free from heart failure hospitalization (HFH). Results Among 1,626 T-TEER patients, 213 (13.1%) met ≥1 exclusion criterion (4.2% of those with LVD, 6.8% of those with RVD, and 3.6% of those with pcPH). Severe LVD, RVD, and pcPH were each associated with significantly lower 1-year HFH-free survival (LVD, 54.6% vs 72.9% [P < 0.001]; RVD, 59.0% vs 73.2% [P = 0.003]; pcPH, 56.2% vs 73.4% [P = 0.021]; median survival follow-up 446 days [Q1-Q3: 192-805 days]). Despite higher NYHA functional class at baseline and follow-up, the rate of ≥1-class improvement was comparable across subgroups (LVD, 51.1% vs 59.4% [P = 0.25]; RVD, 59.7% vs 59.0% [P = 0.90]; pcPH, 51.3% vs 59.4% [P = 0.31]). Overall, “OMT candidates” had lower HFH-free survival than “TTVI-appropriate” patients (58.7% vs 74.3%; P < 0.001) but showed comparable symptomatic relief (≥1 NYHA functional class in 56.2% vs 59.5%; P = 0.68). Conclusions T-TEER may provide symptomatic benefit in selected high-risk patients with severe LVD, RVD, or pcPH. In the absence of randomized evidence, multidisciplinary evaluation at experienced heart valve centers remains essential to balance potential benefit against procedural futility. Further studies are warranted to refine patient selection and optimize outcomes in this challenging cohort.

BACKGROUND:In patients undergoing tricuspid valve transcatheter edge-to-edge repair (T-TEER) for tricuspid regurgitation (TR), NYHA functional class guides assessment, but real-world data on its prognostic value and determinants of symptomatic response remain limited. OBJECTIVES:The objective of the study was to assess the prognostic value of baseline NYHA functional class and identify correlates of NYHA functional class trajectories after T-TEER. METHODS:A total of 3,467 patients from the EuroTR (European Registry of Transcatheter Repair for Tricuspid Regurgitation; NCT06307262) undergoing T-TEER were analyzed. Baseline NYHA functional class was related to survival and heart failure hospitalization. In patients with paired NYHA functional class assessments, correlates of improvement and worsening were evaluated using prespecified multivariable logistic regression. RESULTS:Among 3,424 patients with available baseline NYHA functional class (43 excluded [1.2%]), the median follow-up was 460 days (IQR: 146-856 days). Kaplan-Meier curves demonstrated separation by baseline NYHA functional class for overall and heart failure hospitalization-free survival (both P < 0.001). Two-year mortality was 28.4% (619/3,424; 95% CI: 26.4%-30.4%). In the complete-case Cox cohort (n = 2,185; 63.8%), higher baseline NYHA functional class was associated with 2-year mortality (HR: 1.8 per 1-class increase; 95% CI: 1.5-2.1; P < 0.001). In 1,974 of 3,424 patients (57.7%) with paired NYHA functional class data, NYHA functional classes I/II increased from 16.4% (323/1,974) to 59.4% (1,173/1,974) at follow-up. Improvement was associated with lower body mass index, higher left ventricular ejection fraction, and less residual TR, whereas worsening was associated with lower tricuspid annular plane systolic excursion/systolic pulmonary artery pressure and more residual TR. CONCLUSIONS:In the large real-world EuroTR cohort, baseline NYHA functional class is a strong, independent predictor of 2-year mortality. Symptom trajectories were associated with body mass index, left ventricular ejection fraction, tricuspid annular plane systolic excursion/systolic pulmonary artery pressure, and residual TR.

BACKGROUND:Risk stratification for tricuspid valve transcatheter edge-to-edge repair (T-TEER) is paramount in the decision-making process to appropriately select patients with severe tricuspid regurgitation. OBJECTIVES:The aim of this study was to develop and validate an artificial intelligence-driven risk score, the EuroTR (European Registry of Transcatheter Repair for Tricuspid Regurgitation) score, to predict 1-year mortality in patients undergoing T-TEER. METHODS:The EuroTR score was developed using data from the EuroTR registry, comprising 1,225 patients in the derivation cohort and 601 patients in the validation cohort. On the basis of 18 clinical, laboratory, echocardiographic, and hemodynamic parameters, an extreme gradient boosting algorithm was trained and independently validated against established risk models. RESULTS:Among the entire study cohort (N = 1,826), the overall 1-year survival rate was 82.1% (95% CI: 80.1%-84.2%), with no significant differences between the derivation and validation cohorts. The EuroTR score successfully stratified patients into low-risk and high-risk groups for 1-year mortality after T-TEER (HR: 4.26; 95% CI: 2.71-6.67; P < 0.001), and it significantly outperformed established risk scores such as the EuroScore and the TRI-SCORE in the validation cohort. Beyond mortality prediction (Harrell's C index [validation cohort] = 0.741; 95% CI: 0.699-0.783), increasing EuroTR score values were associated with a higher likelihood of a clinically relevant combined endpoint of 1-year mortality, need for heart failure hospitalization, or persistent dyspnea corresponding to NYHA functional class ≥III. The likelihood of poor outcomes increased from 30.6% in patients with the lowest EuroTR scores (EuroTR risk rank <5%) to 85.5% in the highest risk group (EuroTR risk rank ≥95%). The EuroTR score's performance was confirmed in several subgroups (atrial vs nonatrial tricuspid regurgitation, TRILUMINATE-eligible vs TRILUMINATE-noneligible patients, and patients with vs without cardiac implantable electronic device leads). CONCLUSIONS:The EuroTR score offers an easy-to-use, externally validated, accurate risk stratification tool for patients undergoing T-TEER. It supports personalized treatment strategies and the design of future clinical trials, helping optimize patient selection and enhance shared decision-making within multidisciplinary heart teams.

Abstract Background Tricuspid regurgitation (TR) and right ventricular (RV) remodelling are closely related. Recent European Society of Cardiology/European Association for Cardio-Thoracic Surgery guidelines on valvular heart disease propose adjusted reference values for RV size and function. Aims To determine the predictive value of the proposed RV dilatation and dysfunction thresholds in a real-world interventional cohort. Methods and Results Echocardiographic thresholds were evaluated retrospectively in 651 patients, who underwent transcatheter tricuspid valve repair (TTVr) at two tertiary centres. The primary endpoint was 2-year survival [Kaplan–Meier estimate: 78.6% (74.9–81.9)]. RV strain was the most frequent marker of dysfunction at baseline [free walls strain (FWS) <23% in 80.3%, global longitudinal strain (GLS) <21% in 88.4%]. Proposed cut-offs for RV basal (>24 mm/m2), mid (>21 mm/m2), and tricuspid annular (TA) diameters (>21 mm/m2) were associated with survival (P = .04, <.01, and <.01). Tricuspid annular plane systolic excursion <17 mm was not (P = .24), whereas tissue doppler imaging s′ <10 cm/s and FAC ≤35% were associated with survival (P = .04; .01). Severe RV dysfunction (FWS <11% or GLS <9%) was associated with survival (P < .01; .02). In multivariable analysis, TA >21 mm/m2 [hazard ratio (HR) 2.85 (1.41–5.76); P < .01] and FWS <11% [HR 1.91 (1.07–3.38); P = .03] independently predicted survival. Mortality risk increased for each additional pathological parameter [HR per parameter 1.33 (1.14–1.57); P < .01]. After effective TR reduction (residual TR ≤I; n = 341, 52%), no RV cut-off remained associated with survival. Conclusions TTVr is often performed at an advanced disease stage, and adverse RV remodelling is strongly associated with survival. Nevertheless, effective TR reduction attenuated this prognostic value.

Background Accurate risk stratification is crucial for patients undergoing transcatheter tricuspid valve intervention (TTVI). The performance of existing surgical and TTVI risk scores (TRI-SCORE, STS-TR [Society of Thoracic Surgeons Tricuspid Regurgitation], and TRIVALVE [International Multisite Transcatheter Tricuspid Valve Therapies Registry]) has not been comprehensively evaluated and compared in a contemporary, real-world cohort. Objectives The aim of this study was to assess the discrimination and calibration of these scores in a large international multicenter population of patients undergoing TTVI. Methods This study population included 457 patients from 6 international centers who underwent TTVI (tricuspid transcatheter edge-to-edge repair, transcatheter tricuspid valve replacement, or transcatheter tricuspid annuloplasty) between 2019 and 2024. The performance of the TRIVALVE score was assessed for the 1-year endpoint of death and rehospitalization. The TRI-SCORE and STS-TR scores were assessed for in-hospital and 30-day mortality, respectively. Performance was evaluated using C statistics for discrimination and smoothed calibration plots for calibration. Results All 3 scores demonstrated limitations. The TRIVALVE score showed low discrimination (area under the curve: 0.609) and was well calibrated after its endpoint was refined to exclude non-cardiovascular-related hospitalizations. The surgically derived TRI-SCORE and STS-TR scores were miscalibrated and significantly overestimated mortality. The TRI-SCORE showed an observed-to-expected mortality ratio of 0.13 (95% CI: 0.07-0.23), and the STS-TR score had an observed-to-expected mortality ratio of 0.35 (95% CI: 0.19-0.60). Conclusions The currently available TTVI risk scores derived from surgical or early TTVI cohorts may not be well suited for accurate risk assessment in contemporary TTVI. The surgical scores when applied to TTVI are miscalibrated, and the TRIVALVE score lacks discrimination. There is a need for the development of a contemporary dedicated TTVI risk model validated specifically for this population.