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In a randomized trial involving patients undergoing mitral-valve surgery for degenerative mitral regurgitation, the addition of tricuspid repair resulted in a lower risk of the primary outcome, a composite of reoperation for tricuspid regurgitation, progression of tricuspid regurgitation, or death. Tricuspid repair resulted in more frequent permanent pacemaker implantation.

Severe tricuspid regurgitation is associated with disabling symptoms and an increased risk of death. Data regarding outcomes after percutaneous transcatheter tricuspid-valve replacement are needed. In this international, multicenter trial, we randomly assigned 400 patients with severe symptomatic tricuspid regurgitation in a 2:1 ratio to undergo either transcatheter tricuspid-valve replacement and medical therapy (valve-replacement group) or medical therapy alone (control group). The hierarchical composite primary outcome was death from any cause, implantation of a right ventricular assist device or heart transplantation, postindex tricuspid-valve intervention, hospitalization for heart failure, an improvement of at least 10 points in the score on the Kansas City Cardiomyopathy Questionnaire overall summary (KCCQ-OS), an improvement of at least one New York Heart Association (NYHA) functional class, and an improvement of at least 30 m on the 6-minute walk distance. A win ratio was calculated for the primary outcome by comparing all possible patient pairs, starting with the first event in the hierarchy. A total of 267 patients were assigned to the valve-replacement group and 133 to the control group. At 1 year, the win ratio favoring valve replacement was 2.02 (95% confidence interval [CI], 1.56 to 2.62; P<0.001). In comparisons of patient pairs, those in the valve-replacement group had more wins than the control group with respect to death from any cause (14.8% vs. 12.5%), postindex tricuspid-valve intervention (3.2% vs. 0.6%), and improvement in the KCCQ-OS score (23.1% vs. 6.0%), NYHA class (10.2% vs. 0.8%), and 6-minute walk distance (1.1% vs. 0.9%). The valve-replacement group had fewer wins than the control group with respect to the annualized rate of hospitalization for heart failure (9.7% vs. 10.0%). Severe bleeding occurred in 15.4% of the valve-replacement group and in 5.3% of the control group (P = 0.003); new permanent pacemakers were implanted in 17.4% and 2.3%, respectively (P<0.001). For patients with severe tricuspid regurgitation, transcatheter tricuspid-valve replacement was superior to medical therapy alone for the primary composite outcome, driven primarily by improvements in symptoms and quality of life. (Funded by Edwards Lifesciences; TRISCEND II ClinicalTrials.gov number, NCT04482062.).

Moderate-to-severe mitral regurgitation (MR) and tricuspid regurgitation (TR) are common in patients hospitalized with heart failure (HF) and have been associated with poor quality of life and increased mortality. The impact of these valve lesions on in-hospital decongestion and postdischarge outcomes is less clear. This study analyzed 617 patients hospitalized for acute HF in the Diuretic Optimization Strategies in Acute Heart Failure (DOSE-AHF), Renal Optimization Strategies Evaluation in Acute Heart Failure (ROSE-AHF), and Cardiorenal Rescue Study in Acute Decompensated Heart Failure (CARESS-HF) trials. We assessed biomarkers, physical examination findings, and symptom scores in 288 patients without moderate-to-severe regurgitation, 221 patients with moderate-to-severe MR, and 242 patients with moderate-to-severe TR to evaluate decongestion efficacy and outcomes. For patients with moderate-to-severe MR, there was no difference in weight loss, net fluid loss, or change in creatinine compared with those without moderate-to-severe regurgitation (all p >0.05 at 72 hours). For patients with moderate-to-severe TR, there was more weight loss (−4.77 vs −2.83 pounds at 24 hours, p = 0.029; −9.32 vs −6.99 pounds at 72 hours, p = 0.007), net fluid loss (−4,988 vs −4,581 ml, p = 0.008), and improvement in creatinine (−0.09 mg/100 ml vs +0.06 mg/100 ml at 72 hours, p = 0.002) than those without moderate-to-severe regurgitation. In those with and without moderate-to-severe regurgitation, there was no difference in the change in patient-reported dyspnea or global well-being (all p >0.05 at 72 or 96 hours). For postdischarge outcomes, compared with patients without moderate-to-severe regurgitation, moderate-to-severe MR was associated with a nonsignificant trend toward increased death, rehospitalization, or unscheduled clinic or emergency department visit 60 days after hospital discharge (48.4% vs 38.2% of patients, p = 0.098). This association was not clearly apparent in patients with moderate-to-severe TR (43.8% vs 38.2%, p = 0.407). In conclusion, patients with moderate-to-severe MR experienced similar in-hospital decongestion compared with those without significant regurgitation but had a trend toward worse postdischarge outcomes. Patients with moderate-to-severe TR experienced significantly more decongestion but this was not associated with incremental improvement in dyspnea, global well-being, or clinical outcomes.

Right ventricular (RV) pacing has been linked with lead-induced tricuspid regurgitation (TR), left ventricular (LV) dysfunction, and dyssynchrony, but the effect of pacing on RV function is unclear. We sought to investigate the effect of pacing on RV synchrony, RV function, and TR, and their association with LV function. In this substudy of the PROTECT-PACE (Protection of left ventricular function during right ventricular pacing) study of the effects of RV pacing in patients with preserved ejection fraction, 145 patients (76 RV apex and 69 non-RV apex pacing) had measurable RV parameters. We assessed tricuspid annular plane systolic excursion (TAPSE), time difference between peak TAPSE and peak mitral annular plane systolic excursion (TM-APSE-dif), global LV longitudinal strain, E/e’, TR vena contracta, and TR peak gradient. Echocardiography was performed just after implantation and at 2 years. TR parameters significantly worsened after 2 years, but pacing site was not associated with changes in RV and TR parameters. No temporal change in TAPSE and TM-APSE-dif was observed overall, but worsening of TM-APSE-dif was associated with worsening TAPSE. Global longitudinal strain and E/e’ both deteriorated over 2 years; these changes were significantly associated. In a multivariate regression, worsening global longitudinal strain and worsening TM-APSE-dif were significantly associated with deterioration of TAPSE. Furthermore, increased E/e’ and its deterioration were associated with worsening TR vena contracta and TR peak gradient, respectively. Decreased TAPSE was also associated with deterioration of TR vena contracta. In conclusion, RV pacing appears to worsen TR, an effect which might be caused by elevated LV filling pressure due to LV dysfunction. In this study, RV pacing did not affect RV function during 2-year follow-up, but such an effect might occur if RV dyssynchrony or LV dysfunction occurred after pacing. The effect of RV pacing site on RV and TR mechanics was minor.

Congenital right atrial aneurysm (RAA) is a rare anomaly that may cause arrhythmias, thromboembolism, or heart failure. We report a prenatally diagnosed RAA with coexisting tricuspid valve (TV) dysplasia. Postnatally, the patient showed progressive atrial enlargement, and TV regurgitation. At 9 months, surgery was performed due to high thromboembolic and arrhythmic risk, including aneurysmal wall resection and TV repair. Postoperative recovery was uneventful. In conclusion, this case underscores the need for comprehensive imaging and individualized management in RAA, especially when coexisting valvular abnormalities are present.

Tricuspid regurgitation (TR) is common among patients undergoing surgery for degenerative mitral regurgitation (DMR) and is associated with adverse outcomes. The role of concomitant tricuspid annuloplasty (TA) during mitral valve repair (MVr) remains controversial. To address this, we performed a systematic review and meta-analysis of randomized and observational studies published up to November 2024, comparing isolated MVr versus MVr with concomitant TA in patients with DMR (CRD42024627505). Reconstructed Kaplan–Meier time-to-event data were analyzed using Cox frailty models to evaluate survival, TR progression, and permanent pacemaker (PPM) implantation. Sensitivity analyses included randomized or propensity-matched cohorts. A total of 5 studies, including 3,123 patients, were analyzed. Early (1-year) and long-term (up to 15 years) survival were comparable between isolated MVr and concomitant TA (97.3% vs. 96.9%, HR: 1.25, 95% CI: 0.76 to 2.08, p = 0.381 and 72.2% vs 79.7%, HR: 1.28, 95% CI: 0.96 to 1.72, p = 0.092, respectively). Concomitant TA significantly reduced the risk of ≥moderate TR progression (HR: 0.34, 95% CI: 0.17 to 0.70, p = 0.003). However, PPM implantation was higher with TA during the perioperative period (7.4% vs 1.1%, HR 5.76, 95% CI 3.13 to 10.59) and remained elevated at 2 years. Sensitivity analyses confirmed these findings. In conclusion, in patients undergoing MVr for DMR, concomitant TA effectively prevents TR progression without compromising survival but is associated with increased PPM implantation. These results support a selective, guideline-directed approach to TA based on patient- and disease-specific risk factors.

Background Severe tricuspid regurgitation (TR) is associated with chronic volume overload and right ventricular remodeling (RVR). Transcatheter tricuspid valve repair (TTVr) reduces TR and can improve quality of life (QoL), but the role of preprocedural RVR on TTVr outcomes remains unclear. Aims To investigate the role of RVR on outcomes after TTVr for severe TR. Methods Consecutive patients undergoing TTVr (61% edge-to-edge vs. 39% direct annuloplasty) for severe TR were retrospectively compared by preexisting RVR which was defined as dilation of RV mid-level diameter (> 35 mm) according to guidelines. QoL was evaluated using NYHA class, Minnesota Living with Heart Failure Questionnaire (MLHFQ), 36-Item Short Form Health Survey (SF-36), and 6-min walking distance (6MWD) 1-month after TTVr. Mid-term mortality and heart failure (HF) hospitalization were assessed through 1 year. Results RVR was present in 137 of 223 patients (61%). Symptoms and QoL improved equally in both groups: ≥ 1 NYHA class (57% vs. 65% of patients with vs. without RVR, respectively), 6MWD (36% vs. 34%), MLHFQ (81% vs. 69%), and SF-36 (68% vs. 65%) improvement. One-year mortality and HF hospitalization were significantly higher in patients with RVR (24% and 30%, respectively) than in patients without (8% and 13%, both p  < 0.05). In multivariable analysis, RVR was independently associated with mortality (HR 2.3, 95%CI (1.0–5.0), p  = 0.04) and the combined endpoint of mortality or rehospitalization (HR 2.0, 95%CI (1.1–3.8), p  = 0.03). Conclusions TTVr was associated with significant QoL improvement after 1 month, irrespective of RVR. Despite increased mortality and rehospitalization for heart failure, TTVr in the presence of RVR still provides substantial symptomatic benefit for patients with severe TR. Graphical abstract Role of preexisting right ventricular remodeling (RVR) in symptoms and prognosis after transcatheter tricuspid valve repair (TTVr).

Mitral regurgitation (MR) and tricuspid regurgitation (TR) commonly coexist in patients with heart failure (HF). Their concomitant occurrence carries a much poorer prognosis than isolated valve disease. Transcatheter edge-to-edge repair (TEER) of MR and TR is safe and effective, but there is limited data on combined MR/TR TEER. The study evaluates the safety and efficacy of combined TEER for MR and TR in a real-world cohort. This retrospective safety and efficacy analysis included the first 40 patients treated with combined MR/TR TEER between 2019 and 2021 at our single tertiary care referral centre. Combined procedural success (MR reduction ≥2° and TR reduction ≥1°) was achieved in 80% of the cases. Simultaneous TEER was safe, with no intraprocedural death, myocardial infarction (MI), stroke, or major bleeding. At 1-year follow-up, the median New York Heart Association functional (NYHA) class improved by one grade; twelve patients (30%) died, and fourteen patients (35%) were hospitalized for HF. Procedural success and postprocedural residual MR ≤ 1° were associated with reduced 1-year mortality rates but not HF hospitalizations. Combined MR/TR TEER is safe and reduces MR and TR in most patients, conferring a potential benefit regarding symptoms and prognosis. Randomized controlled trials (RCTs) are needed to rigorously evaluate combination therapy in this setting.

•15.8% of patients who undergo M-TEER are comorbid with pulmonary disease (PD).•The acute procedural success rate exceeded 95%, regardless of PD status.•Prognosis after M-TEER does not differ between patients with and without PD.•Tricuspid regurgitation after M-TEER increases in heart failure rehospitalization. Pulmonary diseases (PD) are frequently associated with impaired cardiac function and the presence of mitral and tricuspid regurgitation (MR and TR). The study aimed to clarify the impact of PD on clinical outcomes following mitral transcatheter edge-to-edge repair (M-TEER). Of the 3,764 patients who underwent M-TEER, 3,666 were included in the analysis and stratified according to the absence or presence of PD before the procedure. The primary endpoint was all-cause mortality, evaluated using Kaplan-Meier analysis. Cardiovascular and non-cardiovascular mortality and HFH (HFH) were also assessed during a 4-year follow-up. Moreover, the prognostic impact of TR improvement after M-TEER was evaluated in patients with and without PD. Of the 3,666 patients, 580 (15.8%) had PD, included fewer women, and exhibited greater frailty compared with those without PD. Within a median follow-up of 432 [314–826] days, all-cause mortality did not differ significantly between patients with PD and those without (150 [25.9%] vs. 682 [22.1%], Log rank P = 0.331). No significant differences were observed in the incidence of cardiovascular mortality, non-cardiovascular mortality, and HFH between the two groups. When stratified by PD status, residual significant TR after M-TEER was significantly associated with HFH both in patients with PD and without PD. The intermediate-term prognosis after M-TEER was comparable between patients with and without PD. In patients with PD, MR was effectively reduced through minimally invasive M-TEER. However, appropriate management of TR after MTEER may be required to improve outcomes in this population. OCEAN-Mitral registry (UMIN-ID: UMIN000023653).

Tricuspid regurgitation (TR) is related to survival, and right atrial (RA) size and function may play a role. This study aimed to assess the impact of RA function measured by strain (RA strain [RAS]) on outcome and end-organ congestion. We enrolled 134 patients (mean age 73 ± 13 years, 62% women) with any TR grade or etiology and a complete echocardiogram, clinical follow-up, and renal function assessment. The primary end point was a combination of overall mortality and right-sided heart failure hospitalization, and the secondary end point was worsening renal function (WRF). After a median follow-up of 23.5 months (interquartile range 12 to 34 months), the combined end point was reached by 31% of patients. Patients with RAS ≤18% showed lower event-free survival (log-rank p <0.001). In the multivariable analysis, RAS ≤18% (HR 3.1, 95% CI 1.1 to 8.8) and pulmonary artery systolic pressure (PASP) (hazard ratio [HR] 1.02, 95% confidence interval [CI] 1 to 1.05) were independent predictors of the primary end point. Patients with RAS ≤18% and PASP >45 mm Hg had the worst outcome (HR 4.3, 95% CI 2 to 9.5). RAS ≤18% (odds ratio 3.22, 95% CI 1.11 to 9.33) and PASP >45 mm Hg (OR 3.2, 95% CI 1.15 to 8.88) were independent predictors of WRF, adjusting for TR severity, left and right ventricular function, age, gender, diabetes, diuretics, atrial fibrillation. The addition of RAS ≤18% had incremental power over PASP and echocardiographic variables of TR severity and right or left ventricular function to predict WRF (p = 0.026). In conclusion, RA function measured by RAS independently predicts mortality and hospitalizations in patients with TR and independently and incrementally predicts WRF over time.