TRIC-I-HF: transcatheter tricuspid repair improved a hierarchical composite in older patients

Design

Randomised 2:1, repair plus medical therapy vs medical therapy alone; hierarchical composite by win ratio

Population

360 patients with symptomatic severe tricuspid regurgitation, mean age 80.3 years

Primary outcome

Hierarchical composite of death, heart-failure hospitalisation and quality of life at 1 year; then death or HF hospitalisation at 3 years

Effect

Win ratio 2.42 (95% CI 1.76 to 3.33); 3-year freedom from death or HF hospitalisation 52.4% vs 21.0%, HR 0.40 (0.29 to 0.55)

TRIC-I-HF randomised 360 patients with symptomatic severe tricuspid regurgitation and a raised risk of future heart-failure events, 2:1, to transcatheter tricuspid repair plus medical therapy (237) or medical therapy alone (123). Mean age was 80.3 years and 56.4% were women.

The first primary end point was a hierarchical composite of death, heart-failure hospitalisation and quality-of-life improvement at 1 year. The win ratio was 2.42 (95% CI 1.76 to 3.33; P<0.001) favouring repair. Because that was significant, the second primary end point was tested: freedom from death or heart-failure hospitalisation through 3 years was 52.4% with repair and 21.0% with medical therapy alone (HR 0.40, 95% CI 0.29 to 0.55). Major adverse events within 30 days occurred in 14 patients (5.9%) in the repair group.

For a physician managing an older patient with right-sided failure and refractory congestion, this strengthens the case for early heart-team referral. The confidence interval around the 3-year medical-therapy estimate is wide (12.7 to 34.6), which tempers precision.

• Refer older patients with symptomatic severe tricuspid regurgitation for heart-team assessment before repeated decompensations.
• Optimise diuretics and heart-failure therapy alongside referral; the comparison group received medical therapy.
• Quality of life was part of the primary outcome, so counsel on symptoms as well as survival.
• Quote the 5.9% rate of major adverse events within 30 days when discussing procedural risk.

Why it matters

Tricuspid regurgitation has long been treated as a late finding to be managed medically; randomised outcome data now exist for an intervention.

Don't overread it

Open-label design and a quality-of-life component make the hierarchical composite vulnerable to expectation effects.

The statistics, in plain English

A win ratio of 2.42 means that, in pairwise comparisons of patients, repair patients did better about 2.4 times as often as medical-therapy patients, ranking death first, then hospitalisation, then quality of life. It combines outcomes of different importance, so look at the separate 3-year hazard ratio (0.40) too.

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