Salvaging the forgotten valve: T-TEER as the new frontier in torrential primary TR

Tricuspid regurgitation (TR) has historically been considered the “forgotten valve disease”, but growing evidence has established its independent prognostic impact and has driven the rapid expansion of transcatheter tricuspid valve interventions. While transcatheter tricuspid edge-to-edge repair (T-TEER) has demonstrated safety and clinical benefit in patients with secondary functional TR, evidence supporting its use in primary TR remains scarce, and surgery continues to represent the standard treatment. However, many patients with primary TR are considered ineligible for surgery because of prohibitive operative risk, creating an important unmet therapeutic need. In this Perspective, we discuss the potential role of T-TEER in selected patients with primary TR through the paradigm of a patient who developed torrential TR following iatrogenic rupture of the septal papillary muscle–chordal apparatus during cardiac device lead extraction. Owing to multiple comorbidities and prohibitive surgical risk, the patient underwent successful transcatheter repair with two PASCAL Ace devices, achieving durable TR reduction and sustained clinical improvement at one-year follow-up. Building on this experience, we review the current evidence supporting transcatheter tricuspid interventions, discuss the anatomical and procedural considerations that may enable T-TEER in selected forms of primary TR, and highlight the limitations of the available literature. We propose that carefully selected anatomical subsets of primary TR may represent an emerging frontier for transcatheter therapies, bridging the gap between guideline-directed management and individualized treatment when surgery is not feasible. Prospective studies are warranted to define patient selection criteria, procedural feasibility, and long-term clinical outcomes.