Transcatheter Tricuspid Valve-in-Valve and Valve-in-Ring Implantation: the TRIVIR registry

Background Transcatheter tricuspid valve-in-valve (TViV) and valve-in-ring (TViR) procedures are increasingly used; however, data on clinical outcomes, valve performance, and symptomatic improvement remain limited. Objectives To evaluate a real-world multicenter cohort undergoing transcatheter TViV and TViR procedures. Methods We conducted an international multicenter registry including patients undergoing TViV/TViR procedures. The TRIVIR Registry evaluated all-cause mortality and a composite endpoint (CE), defined as all-cause mortality, heart failure (HF) hospitalization, and tricuspid bioprosthesis degeneration during follow-up. Results Between 2012 and 2025, 75 patients underwent TViV (n=62) or TViR (n=13) across 16 centers using Sapien (88%) or Myval (12%) valves. Median follow up was 1.86 years (IQR 0.10-2.59). Mean age was 62±13 years, and 69% were women. NYHA class III–IV decreased from 72% at baseline to 13% at 1-3 months and remained low during follow-up. No 30-day deaths occurred, while periprocedural complications occurred in 24% of procedures, mostly minor (17.3%). At 3 years, the Kaplan–Meier estimates of all-cause mortality and CE were 35.6% and 42.9%, and the cumulative incidences of HF hospitalization and tricuspid bioprosthesis degeneration were 16.6% and 11.4%, respectively. Patients who died had markers of advanced disease, including higher NT-proBNP levels, greater diuretic requirements, more frequent pacing/CRT implantation, and higher procedural complication rates. Conclusions TViV/TViR represents a viable treatment strategy and provided sustained symptomatic improvement in high-risk patients. Patients who died exhibited a more advanced clinical profile, highlighting the importance of appropriate patient selection, early referral, and treatment in experienced centers.