Patient Selection for Transcatheter Tricuspid Valve Intervention: Not Too Early, Not Too Late

Tricuspid regurgitation (TR) is a common but frequently underrecognized condition associated with substantial morbidity and mortality. Long regarded as a mere bystander of left-sided heart disease, TR was often left untreated, contributing to late referrals and poor surgical outcomes. The emergence of transcatheter tricuspid valve interventions has broadened therapeutic options, particularly for high-risk or inoperable patients. However, procedural success and clinical benefit critically depend on appropriate patient selection and timely intervention. This review outlines the evolving landscape of TR management, emphasizing the importance of anatomical and clinical stage-adapted device selection. Key determinants of feasibility and prognosis include right ventricular function and dimensions, TR severity, tricuspid valve leaflet and annular remodeling, and hemodynamic congestion. Advanced imaging modalities and invasive hemodynamics provide incremental value for risk stratification. While tricuspid valve transcatheter edge-to-edge repair (T-TEER) and orthotopic valve replacement are the most widely adopted techniques, direct annuloplasty, heterotopic valve replacement, and coaptation enhancement devices may be more appropriate in anatomically advanced stages. Despite symptomatic improvement and reduced heart failure hospitalizations across different treatment modalities, a survival benefit has yet to be demonstrated. Delayed referral remains a challenge, often precluding repair or even replacement strategies. Dedicated risk models may improve prognostication and guide procedural decision-making. Ultimately, a multidisciplinary approach incorporating multiparametric assessment is essential to identify optimal candidates, guide timing, and personalize therapy. Ongoing trials and long-term outcome data are needed to refine treatment algorithms and clarify the role of early intervention in altering the natural course of severe TR.