Transcatheter tricuspid valve intervention versus medical therapy in severe tricuspid regurgitation: a systematic review and bayesian meta-analysis of randomized controlled trials

Background Severe tricuspid regurgitation causes disabling symptoms and predicts adverse outcomes independently of left-sided disease. Transcatheter tricuspid interventions have emerged as minimally invasive therapies; however, their benefit compared with optimized medical therapy remains uncertain. Conventional meta-analyses provide dichotomous statistical conclusions, which may limit clinical interpretability. Purpose To perform a Bayesian meta-analysis of randomized trials comparing transcatheter tricuspid interventions versus optimized medical therapy to quantify the probability of benefit and harm and better inform clinical decision-making. Methods A systematic search was conducted across MEDLINE, Embase, and Cochrane databases for studies evaluating transcatheter tricuspid valve intervention (TTVI) compared with optimized medical therapy (OMT). Primary outcomes included NYHA functional class improvement and Kansas City Cardiomyopathy Questionnaire (KCCQ) score. Bayesian random-effects meta-analyses were performed in R (version 4.5.1) using the bayesmeta package, applying a weakly informative normal prior for the overall effect and a half-normal prior for heterogeneity. Posterior probabilities of benefit were calculated as P(RR > 1) for binary outcomes and P(MD > 0) for continuous outcomes. Results Four randomized controlled trials, encompassing 1,292 patients (710 TTVI vs 582 OMT), with a mean age of 78.6 years (78.6 TTVI vs 78.5 OMT), were analyzed. Atrial fibrillation and hypertension were the most prevalent comorbidities and 57.7% of patients were in NYHA III/IV (59.2% TTVI and 56.0% OMT). At one year, TTVI significantly improved health-related quality of life (KCCQ) compared with OMT (MD 13.28 points; 95% CrI 9.89–16.62; P(MD > 0) 100%; I²=69.4%) and increased the likelihood of NYHA functional class improvement (RR 2.07; 95% CrI 1.09–3.89; P(RR > 1): 98.9%; I²=76.6%). Although heterogeneity was high for both outcomes, prior sensitivity analyses did not demonstrate any meaningful impact on the results. TTVI also reduced tricuspid regurgitation severity (RR 7.71; 95% CrI 4.76–12.42; P(RR > 1): 100%; I²=11%). No evident differences were observed in heart failure hospitalization (RR 0.89; 95% CrI 0.53–1.47; P(RR < 1): 68.1%; I²=0%), all-cause mortality (RR 1.21; 95% CrI 0.78–1.87; P(RR < 1): 19.5%; I²=0%), or cardiovascular mortality (RR 1.07; 95% CrI 0.62–1.83; P(RR < 1): 40.1%; I²=0%). Conclusion Transcatheter tricuspid intervention provides clear symptomatic benefit, but current randomized evidence shows no reduction in mortality or heart failure hospitalization compared with medical therapy, likely due to small sample sizes and short follow-up duration. These findings support intervention for quality-of-life improvement in symptomatic patients, while highlighting that survival benefit may require longer follow-up to emerge.