This module is written to be run, not read. It takes forty-five to sixty minutes with a small group and follows one patient from referral to a Heart Team decision. The group must commit to an answer before each stage reveals what happened. The teaching point is not that transcatheter tricuspid repair works. It is that selecting the right patient for transcatheter tricuspid repair is harder than performing it, and that at several points here the honest answer is “not yet” or “not at all.”
Faculty should resist summarising the evidence up front. Let the group reason, then supply the trial data as the correction. This module sits alongside the case-based sessions in our structural and valvular heart disease course programme.
Learning objectives
By the end of this session, participants should be able to:
- Recognise the right-sided presentation of torrential tricuspid regurgitation, in which fatigue, ascites and oedema dominate and breathlessness is absent.
- Calculate a TRI-SCORE at the bedside and interpret it as a futility instrument, not a referral trigger.
- Assess RV–PA coupling and explain why severe RV dysfunction and precapillary pulmonary hypertension change the conversation about transcatheter tricuspid repair.
- Compare T-TEER and TTVR on expected TR reduction and procedural cost, including a transvenous lead crossing the valve.
- State, in language a patient would understand, what the randomised evidence does and does not promise.
Stage one: decide whether this is a tricuspid problem at all
Present only this much. Do not release the echo yet.
A 76-year-old woman attends clinic three years after mitral valve replacement. She describes progressive abdominal distension, leg oedema and exertional fatigue. She is not breathless. She has permanent atrial fibrillation and a transvenous pacemaker lead placed four years ago. Her furosemide has been escalated to 120 mg daily by her general physician.
Question to the group
What is your leading diagnosis, and what single investigation do you want next? Ask each participant to commit aloud first.
Discussion
Groups reliably chase the mitral prosthesis first, then the liver. Both are usually wrong. The absence of breathlessness is the diagnostic signal, not a reassurance: right-sided failure from severe TR produces venous congestion — hepatic distension, ascites, oedema, early satiety, fatigue — without pulmonary congestion. Patients like this are managed as “diuretic-resistant heart failure” for months, and few reach a discussion about transcatheter tricuspid repair while the right ventricle is still salvageable.
The lead deserves attention here. A lead placed four years ago, in a patient whose symptoms began afterwards, is a mechanistic candidate, not incidental hardware.
Stage two: decide whether the TRI-SCORE tells you to stop
Now release the imaging and bloods. Echocardiography shows torrential TR with a dilated annulus and tethered leaflets, the pacemaker lead crossing the valve. TAPSE is 15 mm, PASP 42 mmHg, LVEF 58%. Creatinine corresponds to an eGFR of 44 mL/min. Total bilirubin is mildly elevated.
Question to the group
Score her TRI-SCORE now, on paper. Give them three minutes, then build the table on the board together.
| TRI-SCORE variable | This patient | Met? | Points | Running total |
|---|---|---|---|---|
| Age ≥70 years | 76 years | Yes | 1 | 1 |
| NYHA class III–IV | Activity-limiting fatigue | Yes | 1 | 2 |
| Right-sided heart failure signs | Ascites, peripheral oedema | Yes | 2 | 4 |
| Daily furosemide dose ≥125 mg | 120 mg daily | No | 0 | 4 |
| Glomerular filtration rate <30 mL/min | eGFR 44 mL/min | No | 0 | 4 |
| Elevated total bilirubin | Mildly elevated | Yes | 2 | 6 |
| LVEF <60% | 58% | Yes | 1 | 7 |
| Moderate or severe RV dysfunction | TAPSE 15 mm | Yes | 1 | 8 |
| Total | Band ≥8 | 8 of maximum 12 | 33–60% in-hospital / post-operative mortality |
Discussion
The TRI-SCORE was derived in 466 patients across 12 French centres and published in the European Heart Journal in 2022. Its eight variables carry a maximum of 12 points, and mortality rises steeply across the bands: roughly 1% at 0–3, 14–18% at 4–5, 25–32% at 6–7, and 33–60% at 8 or above. Its bias-corrected AUROC was 0.753, against 0.629 for EuroSCORE II. The 2025 ESC/EACTS guideline endorses it for futility assessment.
Two near-misses are the whole teaching value. Her furosemide is 120 mg — five milligrams below threshold — and her LVEF 58%, two points below. Let the group argue. The score is a discriminator, not a measurement: a patient at 8 with two variables narrowly unscored sits in the worst band whatever the arithmetic says.
Ask directly: does a score of 8 mean you offer her nothing? No — but surgery becomes very hard to justify, and transcatheter tricuspid repair here must be framed as symptom palliation with explicit uncertainty about survival.
Stage three: decide whether the right ventricle will tolerate transcatheter tricuspid repair
Give them the coupling numbers: TAPSE 15 mm against a PASP of 42 mmHg — a ratio of approximately 0.36 mm/mmHg.
Question to the group
Is this right ventricle a contraindication to transcatheter tricuspid repair, a caution, or neither?
Discussion
This is where the 2025 ESC/EACTS guideline earns its place. Transcatheter tricuspid intervention carries a Class IIa, Level A recommendation for symptomatic high-risk patients on optimal medical therapy — but explicitly conditional on the absence of severe RV dysfunction and precapillary pulmonary hypertension. Heart Team evaluation itself is Class I, Level C.
Her TAPSE of 15 mm indicates impaired but not severe RV dysfunction, and a PASP of 42 mmHg does not by itself establish a precapillary picture — three years after mitral valve replacement, a postcapillary contribution is expected. Right heart catheterisation is the reasonable next step before committing to transcatheter tricuspid repair. Most groups do not volunteer it; push until someone does.
Contrast the 2020 ACC/AHA guideline, which most participants trained on. Tricuspid surgery at the time of left-sided valve surgery in severe TR is its only Class I surgical recommendation, with Class IIa for severe primary TR with right heart failure. It predates the randomised transcatheter era — say so plainly.
Stage four: choosing the device for transcatheter tricuspid repair
Assume catheterisation excludes a precapillary pattern and the Heart Team accepts her.
Question to the group
T-TEER or TTVR — and what do you do about the lead? Ask for a show of hands, then a justification from each side.
What the randomised evidence says
TRILUMINATE Pivotal randomised 572 patients, mean age 78.1, 58.9% female, to TriClip T-TEER. The one-year primary hierarchical composite was carried by KCCQ improvement alone — plus 12.3 points — not by death or heart-failure hospitalisation. At two years, heart-failure hospitalisation was 0.19 versus 0.26 per patient-year, with a joint frailty model HR of 0.72, p=0.02. Moderate-or-less TR at two years was 84% with the device versus 21% among controls who remained on medical therapy; that 21% figure excludes the 142 of 241 eligible controls who crossed over after year one. Stroke was 1.9% versus 2.5%, and new permanent pacemaker 5.5%.
Tri.Fr, published in JAMA in 2024, randomised 300 patients across 24 French and Belgian centres. The Packer clinical composite improved in 74.1% versus 40.6%, p<0.0001, with KCCQ 69.9 versus 55.4, deployment success 97.3% and 30-day major adverse events of 0.7%.
TRISCEND II randomised 400 patients 2:1 to EVOQUE TTVR. Win ratio was 2.02 (1.56–2.62), with mild-or-less TR at 30 days in 95.3% versus 2.3%. The costs were substantial: new pacemaker or CIED in 24.7%, severe bleeding 10.4%, cardiovascular death 3.1% at 30 days. The two-year data presented at ACC.26 showed sustained TR control around 95% and sustained symptom benefit — with no all-cause mortality difference in the primary comparison.
The lead problem
Her lead crosses the valve and contributes to tethering. This is the crux of the decision and the part groups handle least well. TTVR gives far more complete TR abolition, but jails the lead and carries roughly a one-in-four risk of a new pacemaker or CIED requirement — serious in a patient who already depends on a device. T-TEER, the transcatheter tricuspid repair option in the narrow sense, may achieve less TR reduction with a tethering lead in the grasping zone, but leaves the lead accessible and carries a 5.5% new pacemaker rate. The choice is not “which device is better” but “which trade-off is this woman willing to accept.”
Stage five: decide what you are actually promising her
Question to the group
Write one sentence you would say to her in clinic about expected benefit. Collect three or four aloud.
Discussion
Real-world data calibrate the promise. The bRIGHT post-approval registry (JACC 2024;84:607–616) enrolled 511 patients at 26 sites, 88% with massive or torrential TR, and reported 81% moderate or less at one year with a KCCQ gain of 19 points. The single-arm three-year TRILUMINATE cohort — 98 patients, not the randomised Pivotal trial — showed 79% moderate or less, NYHA III/IV falling from 76% to 19%, heart-failure hospitalisation from 0.56 to 0.14 per patient-year, and mortality of 27%.
The honest sentence after transcatheter tricuspid repair is close to this: “We can very probably make you less congested and able to do more. We cannot tell you it will make you live longer.” Anyone whose sentence implied survival benefit has misread the trials.
Facilitator notes
Run stages one to three in the first half. Keep the TRI-SCORE table on the board throughout — everything after stage two is argued against that 8.
Three things groups get wrong, in order of frequency:
- Treating the TRI-SCORE as a referral tool. It is a futility instrument. A high score does not select for transcatheter tricuspid repair; it argues against surgery and demands honesty about expectations.
- Quoting the 63% control figure from TRILUMINATE. That number includes crossovers. The rate among controls who stayed on medical therapy is 21%. Correct this immediately if it appears.
- Presenting the three-year data as randomised. Those are the 98-patient single-arm results. Label them every time.
A fourth, subtler error: groups treat the pacemaker rate difference between T-TEER and TTVR as a footnote rather than the decisive variable in a lead-dependent patient. Push back when it is skipped.
For pre-reading, direct participants to the tricuspid material in the cardiology learning centre and the trial summaries in the structural heart reference library.
Take-home messages
- Right-sided congestion without breathlessness is a tricuspid presentation until proven otherwise.
- A TRI-SCORE of 8 places this patient in the 33–60% band and effectively closes the surgical option.
- Guideline support is Class IIa, Level A — conditional on absent severe RV dysfunction and precapillary PH. Catheterise before committing.
- In transcatheter tricuspid repair, T-TEER and TTVR differ most in TR abolition and pacemaker risk, and an existing lead drives the decision.
- The randomised evidence for transcatheter tricuspid repair supports symptom and TR-grade benefit, not a demonstrated mortality benefit.
Close by returning to the opening claim. The randomised era has settled that transcatheter tricuspid repair reduces TR grade and improves symptoms; it has not settled that it prolongs life, and the patients most likely to be referred are precisely those in whom futility is the live question. Run well, this module leaves a group less certain that transcatheter tricuspid repair is the answer, and considerably better at working out for whom it is.
Written and clinically reviewed by Dr A M Thirugnanam, MD, MSICP, FSCAI, Ph.D., Senior Interventional Cardiologist. Last reviewed 6 August 2026. This article is for medical education and does not replace individual clinical judgement or local protocols.