Pitfalls of transcatheter tricuspid valve replacement: lessons from a decade of experience

ascites was observed in 20–50%, suggesting advanced right heart failure (HF). In patients undergoing TV surgery, delayed operative intervention in patients with RV dysfunction and end-organ damage including renal and hepatic dysfunction negatively impacts perioperative outcomes (6). However, predictors of prognosis in patients undergoing TTVR remain to be defined. The recent real-world European commercial EVOQUE registry demonstrated that preoperative RV dysfunction was associated not only with adverse short-term outcomes including in-hospital mortality but also with reduced clinical improvement at follow-up (7). This would suggest that TTVR is best avoided in patients with advanced RV dysfunction, with likely preference for tricuspid transcatheter edge-to-edge repair (TEER) given it rarely abolishes TR. In addition, invasive hemodynamic assessment to exclude precapillary pulmonary hypertension and/or pulmonary vascular resistance >5 WU is important to avoid post-TTVR afterload mismatch and RV failure. The pulmonary artery (PA) to RV coupling index, assessed either non-invasively measured as PA systolic pressure divided by tricuspid annular plane systolic excursion (TAPSE) ( ≤ 0.406) (8) or invasively measured as PA systolic pressure/TAPSE ratio (<0.303) (9), has been linked to worse outcomes in patients undergoing TEER, and likely also