Torrential tricuspid regurgitation and outcomes after transcatheter tricuspid edge-to-edge repair: Insights from the EuroTR registry

Background Patients with torrential tricuspid regurgitation (TR; grade V of V) represent a particularly high-risk subgroup with advanced right-sided heart disease and pronounced structural remodeling. Despite growing experience with transcatheter tricuspid edge-to-edge repair (T-TEER), the clinical phenotype, procedural complexity, and outcome determinants in this subgroup remain insufficiently characterized. Large-scale real-world registries provide an opportunity to better define these features. Methods Consecutive patients undergoing T-TEER enrolled in the multicenter EuroTR registry (ClinicalTrials.gov Identifier: NCT06307262) were analyzed. Tricuspid regurgitation severity was graded using a five-grade scheme, with torrential TR defined as grade V of V. Baseline clinical, echocardiographic, procedural, and invasive hemodynamic characteristics, as well as outcomes, were compared between patients with torrential versus non-torrential TR (grades III–IV of V). Clinical outcomes included functional status, heart failure rehospitalization, and all-cause mortality during follow-up. Results Among 2,846 patients undergoing T-TEER, 580 (20.4%) presented with torrential TR. Baseline age, BMI, and overall comorbidity burden were comparable; however, patients with torrential TR more frequently had right ventricular pacemaker leads (32.4 vs. 26.8%, p=0.008) and atrial fibrillation (93.2 vs. 89.4%, p=0.008). Echocardiography demonstrated more advanced right heart remodeling, including larger right ventricular end-systolic area (18.0 [13.5–22.4] vs. 15.0 [11.4–20.0] cm², p<0.001) and tricuspid annular diameter (46.0 [41.0–50.0] vs. 43.0 [38.0–48.0] mm, p<0.001), while TAPSE was similar. Invasive hemodynamics showed higher right atrial pressures and v-waves (both p<0.001), accompanied by laboratory signs of more advanced hepatic congestion. Procedural complexity was higher in patients with torrential TR, reflected by a greater number of implanted devices and longer procedure times (both p<0.001). Acute echocardiographic outcomes were less favorable, with lower rates of TR ≤ mild (22.0 vs. 52.8%) and higher residual TR≥3+ at discharge (39.3 vs. 11.6%; p<0.001). Despite comparable functional improvement and heart failure rehospitalization rates, torrential TR was associated with higher 2-year all-cause mortality (p=0.032). Conclusion In this large real-world registry, torrential TR was associated with more advanced right-sided remodeling, greater procedural complexity, and higher long-term mortality after T-TEER. While symptomatic benefit can be achieved, these findings underscore the importance of careful patient selection and expectation management in this challenging population.