IntroductionTranscatheter edge-to-edge repair (TEER) is an increasingly performed intervention in patients with symptomatic tricuspid regurgitation (TR) at high surgical risk. Up to date, there is no study comparing TEER and minimally-invasive beating-heart tricuspid valve surgery (MIC-TVS) in a high-risk patient cohort. This study evaluated clinical outcomes of high-risk patients with TR after TEER in comparison to MIC-TVS.

Methods

This is a retrospective observational multicentre study of patients treated for TR with TEER using edge-to-edge repair (n=211) or isolated MIC-TVS beating heart procedures (n=28) between 2016 and 2021. Endpoints were all-cause mortality at 30-days and one year, grade of TR at discharge and one year, all-cause mortality at one year stratified by TRI-SCORE (6< vs. ≥6 points). Kaplan-Meier estimation was used for survival analyses and curves were compared using the log-rank test.

Results
TR reduction in comparison to baseline was significantly more pronounced in the MIC-TVS group (p<0.001) (Figure 1B). 30-day mortality was 2.8% (6/211) in TEER vs. 10.7% (3/28) in MIC-TVS (p=0.07). The overall survival at one year was 80.4% after TEER and 78.6% after MIC-TVS (p=0.67) (Figure 1C). One year survival stratified by TRI-SCORE <6 vs. ≥6 points was 89.7% vs. 67.6% in TEER (p<0.01) (Figure 1D) and 90.0% vs. 50.0% in MIC-TVS patients (p<0.01) (Figure 1E). At six months, 100% (171/171) of TEER patients and 95.4% (21/22) of MIC-TVS patients were in NYHA class I/II (p=1.00) and cardiac related rehospitalization occurred in 8.5% (18/211) in TEER and in 14.3% (4/28) in MIC-TVS (p=0.30).

Discussion
Many TR patients are at high surgical risk and therefore catheter-based interventions for TR are increasingly performed. TEER is the most widely used technique, and the safety and effectiveness have been proven. The study groups consisted of elderly patients at high-risk for surgery (predicted risk by TRI-SCORE 8-14%). In our analysis, both treatment options led to continued reduction in TR, but reduction was more significantly pronounced in MIC-TVS. The possible benefits of more efficient TR reduction were possibly counterbalanced by the slightly higher post-procedural mortality rate. In addition, before initiation of any interventional or surgical treatment best medical guideline directed therapy should be enforced. Given that improvement of right-ventricular function after TR correction is associated with improved prognosis and absolute elimination of TR may result in right heart failure, TEER seems an attractive option in high-risk patients with TR. The role of transcatheter tricuspid valve replacement and its prognostic benefits in this setting are currently under investigation.
Conclusion

On basis of our analysis, timing of invasive treatment in patients in TR is a remaining clinical challenge. In times when edge-to-edge repair is the most advanced transcatheter solution and data on catheter-based tricuspid valve replacement are limited, more evidence is needed. Larger studies should be performed to confirm our findings and to assist heart teams in the decision-making process in patients with tricuspid valve disease. These results should form the basis for randomized trials of TEER vs MIC-TVS.