Transcatheter tricuspid repair in symptomatic severe regurgitation

Design

Randomised 2:1, open-label, multicentre

Population

360 patients with symptomatic severe tricuspid regurgitation, mean age 80

Primary outcome

Hierarchical composite at 1 year; then death or heart failure admission through 3 years

Effect

Win ratio 2.42 (1.76–3.33); HR 0.40 (0.29–0.55)

TRIC-I-HF, published in NEJM in August, randomised 360 patients with symptomatic severe tricuspid regurgitation and a raised risk of heart failure events, 2:1 to transcatheter repair plus medical therapy or medical therapy alone. Mean age was 80, and 56% were women.

The hierarchical primary endpoint — death, heart failure admission and quality-of-life improvement at one year — favoured repair with a win ratio of 2.42. Through three years, freedom from death or heart failure admission was 52.4% with repair against 21.0% with medical therapy (HR 0.40). Major adverse events within 30 days occurred in 5.9% of the repair group.

Earlier tricuspid trials mainly showed quality-of-life gains. This one reports a hard composite outcome over three years, which makes referral for assessment, rather than diuretics alone, the more defensible default. The trial was unblinded, and access to these devices in India is limited.

• Refer symptomatic severe tricuspid regurgitation for a heart team assessment rather than escalating diuretics alone.
• Quantify the regurgitation properly on echo; moderate and severe are often confused.
• Expect most candidates to be older and frail, and include that in the discussion.
• Explain that the benefit included fewer admissions as well as better symptoms.

Why it matters

Tricuspid regurgitation, long managed with diuretics alone, now has trial evidence for intervention against hard outcomes.

Don't overread it

The trial was unblinded, and quality of life — part of the primary endpoint — is open to expectation effects.

The statistics, in plain English

A win ratio of 2.42 means that comparing patients pairwise on death first, then admissions, then quality of life, repair 'won' about 2.4 times as often as it lost. The three-year HR of 0.40 means a 60% lower rate of death or heart failure admission.

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