Transcatheter vs Surgical Tricuspid Valve Repair: An Analysis of Medicare Beneficiaries

BACKGROUND In patients with tricuspid regurgitation (TR), surgical and transcatheter interventions aim to impact outcomes and symptomatic quality of life. Compared tricuspid transcatheter edge-to-edge repair (T-TEER) to isolated surgical tricuspid valve repair (TVr). METHODS Assessing United States Medicare data (2018-2022), excluding endocarditis and rheumatic disease, we evaluated all patients undergoing isolated T-TEER (n=1,540) or isolated TVr (n=1,221). International Classification of Diseases 10th revision codes were used to define comorbidities and frailty using validated metrics. Doubly robust risk adjustment was performed with inverse probability weighting, multilevel regression, and competing-risk time-to-event analyses. Outcomes of interest include procedural mortality, pacemaker, and kidney injury as well as three-year freedom from death, valve reintervention and heart failure readmission. RESULTS Surgical TVr was associated with higher unadjusted hospital mortality (8.8% vs 2.1%, p<0.001), but lower 3-year mortality (20.8% vs 26.2%, p=0.025) and valve reintervention (0.9% vs 2.1%, p=0.015). After risk adjustment, surgical TVr was associated with higher hospital mortality (OR 2.83, p<0.001) but improved longitudinal survival compared to T-TEER (HR 0.76, p=0.012). Surgical TVr was associated with lower rates of overall readmission (HR 0.87, p=0.040), heart failure-related readmission (HR 0.79, p=0.001), and valve reintervention (HR 0.83, p=0.003) at 3 years compared to T-TEER. CONCLUSIONS Among Medicare patients with symptomatic TR, surgical TVr was associated with higher perioperative risk, but improved risk-adjusted 3-year survival, heart failure readmission and valve reintervention compared to T-TEER. These contemporary data may inform future trial designs and heart team decision making for patients with severe symptomatic TR.