Choosing Between Tricuspid Repair or Replacement: Decision Algorithms.

Transcatheter tricuspid valve (TV) interventions have transformed the treatment of TV disease. Among available therapies, transcatheter tricuspid edge-to-edge repair has shown favorable safety, symptom relief, quality-of-life improvement, and reduction of heart failure hospitalizations in selected patients with severe tricuspid regurgitation (TR). In complex cases, repair may not result in optimal TR reduction, whereas transcatheter TV replacement (TTVR) offers TR elimination, irrespective of the valve anatomy. However, TTVR is less widely available, requires long-term anticoagulation, and can lead to periprocedural adverse events. As device options expand, careful procedural selection has become increasingly important and must be guided by a comprehensive, multidisciplinary assessment. Key factors include TV anatomy, right ventricular function, pulmonary pressures and resistance, right ventricular-pulmonary artery coupling, endocardial device leads, bleeding risk, imaging quality, and anticoagulation tolerance. Multimodal imaging, including echocardiography and cardiac computed tomography, along with right heart catheterization is an essential step for procedural planning. In addition, preprocedural optimization with diuresis, rhythm control, and collaboration with heart failure and electrophysiology specialists are essential to ensure optimal procedural outcomes. Transcatheter tricuspid edge-to-edge repair and TTVR should be viewed as complementary therapies that each play a role in tailoring transcatheter TV intervention to individual anatomical and clinical patient characteristics. This review presents a framework based on evidence and experience for procedural selection, highlighting the importance of individualized evaluation and multidisciplinary care. A stepwise algorithm is proposed to support decision-making in patients with severe TR.