When Does Treating Tricuspid Regurgitation Change the Course of Heart Failure?
Background Transcatheter tricuspid valve interventions (TTVI) have transformed the management of severe tricuspid regurgitation (TR). Although randomized trials have consistently shown improvements in TR severity, symptoms, and quality of life, their effects on heart failure hospitalization (HFH) and mortality remain less certain. Methods We critically examined evidence from four randomized trials, TRISCEND II, TRILUMINATE, Tri.Fr, and TRIC-I-HF, comparing transcatheter tricuspid repair or replacement with medical therapy, with an emphasis on clinical outcomes, patient selection, and timing of intervention. Results TRISCEND II, TRILUMINATE, and Tri.Fr demonstrated substantial reductions in TR severity and improvements in patient-reported outcomes without significant reductions in mortality or HFH at 1 year. Extended follow-up from TRILUMINATE suggested fewer recurrent HFHs at 2 years (hazard ratio [HR], 0.72; 95% confidence interval [CI], 0.53–0.98). In contrast, TRIC-I-HF, which enrolled patients at increased risk for heart failure events, demonstrated improved freedom from death or first HFH at 3 years (52.4% vs. 21.0%; HR, 0.40; 95% CI, 0.29–0.55). These findings suggest that baseline clinical risk, disease stage, and duration of follow-up may influence the prognostic benefit of TR correction. However, open-label designs, treatment crossover, and differences in trial populations complicate interpretation. Conclusions Randomized evidence supports TTVI for improving symptoms and health status, while emerging data suggest potential prognostic benefits in selected high-risk patients. The next challenge is defining the optimal therapeutic window-intervening when TR becomes clinically consequential but before irreversible right ventricular dysfunction and end-organ damage develop. Refining patient selection through assessment of right ventricular reserve, pulmonary vascular disease, and systemic congestion will be essential to determine when TR correction meaningfully alters clinical outcomes.