Choosing Between Tricuspid Repair or Replacement: Decision Algorithms

Area of Science:

• Cardiology
• Interventional Cardiology
• Cardiac Surgery

Background:

• Transcatheter tricuspid valve (TV) interventions are evolving for treating TV disease.
• Transcatheter tricuspid edge-to-edge repair shows promise for selected patients with severe tricuspid regurgitation (TR), improving symptoms and reducing hospitalizations.
• Transcatheter TV replacement (TTVR) offers complete TR elimination but has limitations like availability and anticoagulation needs.

Purpose of the Study:

• To present a framework for selecting the appropriate transcatheter TV intervention (repair vs. replacement) for patients with severe TR.
• To emphasize the importance of individualized patient assessment and multidisciplinary care in procedural selection.
• To propose a stepwise algorithm to guide decision-making in severe TR management.

Main Methods:

• Review of current evidence and clinical experience in transcatheter TV interventions.
• Highlighting key factors for procedural selection: TV anatomy, RV function, pulmonary pressures, device leads, bleeding risk, imaging, and anticoagulation tolerance.
• Utilizing multimodal imaging (echocardiography, CT) and right heart catheterization for preprocedural planning and patient optimization.

Main Results:

• Transcatheter tricuspid edge-to-edge repair and TTVR are complementary therapies tailored to patient-specific characteristics.
• Optimal outcomes depend on comprehensive preprocedural evaluation and optimization, including diuresis, rhythm control, and specialist collaboration.
• A proposed algorithm aids in selecting the best transcatheter approach for severe TR.

Conclusions:

• Procedural selection for transcatheter TV interventions requires a thorough, multidisciplinary assessment.
• Individualized evaluation of patient anatomy and clinical factors is paramount.
• Both transcatheter tricuspid edge-to-edge repair and TTVR have distinct roles in managing severe TR.