Have TRILUMINATE, TRISCEND II, and TRI.FR changed the way you think about tricuspid regurgitation?
Hahn: Having worked in the tricuspid field since 2012 and having seen the remarkable effects on patient-reported outcomes from the beginning, I had little doubt that randomized trials would confirm these benefits. The early compassionate-use experience already suggested improvements in congestion, renal function and diuretic responsiveness.
The randomized trials have now confirmed significant improvements in symptoms and quality of life in carefully selected patients. Importantly, emerging data demonstrate reductions in heart failure hospitalizations, particularly with longer follow-up after transcatheter edge-to-edge repair (T-TEER) and in patients with more advanced tricuspid regurgitation (TR) undergoing transcatheter tricuspid valve replacement (TTVR).
I would not say these trials fundamentally changed my thinking, but they validated what many of us observed clinically: what matters most to patients is feeling better. I believe that benefits beyond symptoms, including HF hospitalization and potentially mortality reduction, will become more evident with longer follow-up or in higher-risk populations.
Are we moving toward significantly earlier intervention in patients with severe TR?
Hahn: Patients with symptomatic TR represent a highly heterogeneous population. The fact that current T-TEER studies achieve reduction to mild or less TR in only approximately half of patients raises the question whether intervention should occur earlier, before patients progress to massive or torrential TR.
However, earlier intervention requires better disease awareness, improved detection, more accurate quantification and better risk assessment. Clinical scores such as TriSCORE, STS-TVS and EuroTR may help define optimal timing by integrating clinical factors, biomarkers and echocardiographic parameters.
Which patients are currently best suited for repair, and which for replacement?
Hahn: The goal of any tricuspid intervention should be reduction of TR to mild or less. Several anatomical predictors determine the likelihood of successful T-TEER, including coaptation gap, tenting height, leaflet morphology, jet location, RV remodeling, and CIED-related TR.
Patients with multiple predictors of poor T-TEER success should be considered for orthotopic TTVR. However, replacement also introduces specific considerations including bleeding risk, pacemaker implantation, lead entrapment, HALT requiring anticoagulation, acute RV adaptation and unknown durability.
Repair and replacement will likely coexist. T-TEER has excellent safety but requires imaging expertise and has limitations in achieving optimal TR reduction in complex anatomies. TTVR offers predictable elimination of TR and easier procedural reproducibility, especially as next-generation devices address current limitations.
How important are RV function, systemic congestion, and frailty in treatment timing and patient selection?
Hahn: Baseline RV function is a key determinant of outcomes after TTVI. However, we still lack a complete understanding of RV contractile reserve and reversibility after intervention.
Emerging parameters such as RV–PA coupling and effective RVEF may improve future patient selection. Systemic congestion remains one of the most important clinical signs of advanced TR, and worsening diuretic responsiveness may represent an important trigger for intervention.
Frailty is another critical component, particularly because most patients treated for TR are elderly. Future treatment algorithms need to integrate not only anatomy and risk scores but also patient goals and shared decision-making within an experienced multidisciplinary Heart Team.
Do you believe tricuspid interventions will eventually improve prognosis beyond symptom relief and quality of life?
Hahn: Yes. Current evidence already shows strong improvements in symptoms and patient-reported outcomes, and signals for reductions in heart failure hospitalization are emerging. I believe prognostic benefits will become more apparent with longer-term follow-up and appropriate patient selection.
What do you currently consider the biggest unresolved challenge in the field: timing, patient selection, imaging, or evidence?
Hahn: There remain several unresolved challenges. Multimodality imaging is central to redefining TR mechanisms, disease severity, procedural planning, device selection and follow-up.
More automated and reproducible approaches to quantify TR severity and right heart function would significantly advance the field.
However, the biggest hurdle remains evidence. Unlike left-sided valve interventions, where mortality benefits rapidly changed practice, current TR data are mainly driven by improvements in symptoms and quality of life, with HF hospitalization benefits emerging later. Stronger evidence will likely be required to overcome clinician hesitation and further change guideline recommendations.
How do you expect the results of these trials to influence future guidelines and everyday clinical practice in the US and Europe?
Hahn: Guidelines are already evolving. The European recommendations emphasize comprehensive assessment of TR etiology, disease stage, RV/LV function, pulmonary hypertension, procedural risk and likelihood of recovery by an experienced multidisciplinary Heart Team.
Transcatheter tricuspid interventions now have a role for improving quality of life and promoting RV remodeling in selected high-risk symptomatic patients without advanced RV dysfunction or severe pulmonary hypertension. The updated ACC/AHA guidelines will further define how these therapies enter routine clinical practice.
