Applying the 2025 ESC/EACTS Recommendations for the Treatment of Severe Tricuspid Regurgitation to Real-World Practice.

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.