Transcatheter tricuspid repair: freedom from death or heart-failure admission at three years, 52% versus 21%

Design

randomised, 2:1, open-label trial (TRIC-I-HF)

Population

360 patients with symptomatic severe tricuspid regurgitation at raised risk of heart-failure events; mean age 80.3 years, 56.4% women

Primary outcome

hierarchical composite of death, heart-failure hospitalisation and quality-of-life improvement at 1 year, by win ratio; then death or heart-failure hospitalisation through 3 years

Effect

win ratio 2.42 (95% CI 1.76-3.33; P<0.001); freedom from death or HF hospitalisation at 3 years 52.4% vs 21.0% (HR 0.40; 95% CI 0.29-0.55)

TRIC-I-HF randomised 360 patients with symptomatic severe tricuspid regurgitation and raised risk of heart-failure events, 2:1, to transcatheter tricuspid repair plus medical therapy or medical therapy alone. The population was old — mean age 80 — and 56% were women. The hierarchical primary endpoint, combining death, heart-failure hospitalisation and quality-of-life improvement at one year, gave a win ratio of 2.42.

The second primary endpoint is the one that will move practice. Freedom from death or heart-failure hospitalisation through three years was 52.4% with repair against 21.0% with medical therapy alone, a hazard ratio of 0.40. Earlier transcatheter tricuspid trials established that the procedure reduces regurgitation and improves symptoms; whether it altered hard outcomes was the open question. This trial answers it in a selected population.

Procedural risk was modest: major adverse events within 30 days in 5.9% of the repair group. That number belongs in the consent conversation alongside the benefit.

The practical constraint in India is access rather than evidence. Transcatheter tricuspid repair is performed at a small number of centres and cost is substantial; a patient who would qualify on these criteria still needs a referral pathway that exists. Identifying them remains worthwhile, because the comparator arm here did badly.

• Grade tricuspid regurgitation formally in symptomatic heart failure rather than noting it as incidental
• Flag symptomatic severe tricuspid regurgitation for structural heart discussion even in patients in their eighties
• Quote the 30-day major adverse event rate of 5.9% when consenting, alongside the three-year benefit
• Check whether a referral pathway to a structural centre exists before raising the option with a family
• Continue optimising medical therapy regardless — the trial tested repair added to it, not instead of it

The statistics, in plain English

A win ratio compares every patient in one group with every patient in the other, ranking them first on death, then on heart-failure hospitalisation, then on quality of life; 2.42 means the repair patient 'won' roughly two and a half times as often as the medical-therapy patient. It is a useful summary but it does not tell you how much longer anyone lived. The three-year figures do: 52.4% versus 21.0% free of death or heart-failure admission, with confidence intervals of 43.2-63.6 and 12.7-34.6 that do not overlap. The 2:1 randomisation means the medical-therapy arm is smaller and its estimates correspondingly less precise, which is visible in the wider interval.

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