T-TEER vs Annuloplasty: Edge-to-Edge More Effective for Tricuspid Regurgitation

T-TEER vs TTVA: Which strategy for secondary tricuspid regurgitation?

The treatment of severe and symptomatic secondary tricuspid regurgitation (TR) has been transformed by the advent of percutaneous technologies. While transcatheter edge-to-edge repair (T-TEER) and transcatheter tricuspid valve annuloplasty (TTVA) currently constitute two therapeutic pillars, the clinician still lacks direct comparative data to guide technical choices. This study addresses this lack of evidence by analyzing the outcomes of 1,122 patients treated between 2017 and 2024 (882 T-TEER and 240 TTVA).

The primary objective is to compare the procedural efficacy and medium-term clinical outcome of these two strategies. The study specifically seeks to determine which of these approaches offers the most durable reduction in regurgitation grade while minimizing the risks of peri-procedural complications.

The authors test the hypothesis of a disparity in results based on strict success criteria (residual TR ≤ 1+), the reintervention rate, and a composite endpoint of all-cause mortality or hospitalization for heart failure at one year. To refine this comparison, the analysis focuses on 111 pairs of patients perfectly matched by propensity score, thus isolating the real impact of the surgical technique on patient outcomes.

Study design and population

This comparative study is based on the prospective follow-up of consecutive patients treated for severe and symptomatic secondary tricuspid regurgitation (TR) between 2017 and 2024. The design aims to compare two distinct transcatheter repair strategies.

• Initial sample: 1,122 patients included (882 underwent T-TEER and 240 underwent TTVA).
• Matching: To ensure group comparability, 1:1 propensity-score matching was performed, identifying 111 perfectly balanced pairs.

Protocols and experimental groups

The study segments subjects into two groups according to the surgical approach adopted:

• T-TEER Group: Tricuspid Transcatheter Edge-to-Edge Repair.
• TTVA Group: Transcatheter Tricuspid Valve Annuloplasty.

Evaluation criteria and analysis methods

Researchers evaluated the efficacy and safety of the procedures using several standardized criteria:

• Technical performance: Analysis of the residual TR rate (grades ≤ 1+ and ≤ 2+) at the time of hospital discharge and proportion of patients with a grade reduction ≥ 2.
• Safety: Overall procedural complication rate.
• 1-year clinical follow-up: Evaluation of a composite endpoint combining all-cause mortality and first hospitalization for heart failure, as well as reintervention rates and symptom improvement.

Results: Technical superiority of T-TEER and clinical equivalence at one year

Matched-pair analysis highlights significant disparities in favor of T-TEER (edge-to-edge repair) regarding immediate hemodynamic efficacy and periprocedural safety, despite comparable mid-term clinical outcomes.

Efficacy of tricuspid regurgitation (TR) reduction

At the time of hospital discharge, T-TEER demonstrated a superior ability to reduce TR severity compared to percutaneous annuloplasty (TTVA). While the reduction of at least two TR grades was comparable between the two groups, absolute technical success rates clearly favor T-TEER.

Safety profile and procedural complications

The most significant point of divergence concerns the safety of the procedure. T-TEER presents a clearly more favorable risk profile:

• Overall complication rate: 4.5% for T-TEER versus 27.0% for TTVA (P < 0.001).
• This difference highlights a procedural complexity or a potentially more demanding learning curve for annuloplasty techniques.

1-year clinical follow-up

Despite the initial technical superiority of T-TEER in reducing TR, "hard" clinical endpoints show no statistically significant difference at 12 months after adjustment. Symptomatic improvement and reintervention rates remained similar.

In summary, while T-TEER stands out as a safer and more effective procedure for mechanically reducing TR, TTVA maintains equivalent clinical stability at one year in selected patients, suggesting that the reduction in TR achieved by annuloplasty, although less profound, may be sufficient to stabilize the condition of certain patients in the short term.

Clinical analysis: technical efficiency vs. procedural safety

The results of this study mark a clear distinction between the technical performance and the safety profile of the two approaches. T-TEER proves superior in achieving a deeper reduction of tricuspid regurgitation (TR), with 87.7% of patients reaching TR ≤ 2+ compared to 67.6% for TTVA (p < 0.05). Even more significant for clinical practice: the complication rate is six times lower with T-TEER (4.5% vs 27.0%). This increased safety makes it a robust first-line option, particularly for fragile patients frequently encountered in interventional cardiology.

Limitations and perspective

The study highlights, however, an early decorrelation between technical success and lasting clinical benefit. At one year, the composite endpoint (mortality and hospitalizations for heart failure) shows no statistically significant difference (75.0% for T-TEER versus 79.8% for TTVA; p = 0.408). The matched sample of 111 pairs, although balanced, limits the statistical power to identify benefits on overall survival. The lack of follow-up beyond 12 months prevents concluding on the superiority of one approach regarding long-term ventricular remodeling.

Implications for practice

Although both techniques offer comparable symptomatic improvement, T-TEER stands out for its lower invasiveness and immediate efficacy on the regurgitation grade. In a context where comparative data were previously limited, these results position T-TEER as the most efficient short-term strategy, even though TTVA might remain relevant for specific anatomies where annuloplasty provides a mechanically different correction.

Summary of results

T-TEER surpasses TTVA in terms of immediate reduction of tricuspid regurgitation (87.7% vs 67.6% of leakage ≤ 2+) and peri-procedural safety (4.5% complications versus 27.0%). At one year, both approaches nevertheless offer equivalent clinical benefits on survival and rehospitalization for heart failure (75.0% vs 79.8%).

In concrete terms, for the practitioner:

• Prioritise T-TEER as the first-line treatment in patients eligible for both techniques due to its significantly superior safety profile and its effectiveness in reducing leakage.
• Anticipate increased monitoring in the event of TTVA, as the risk of peri-procedural complications is six times higher than for T-TEER.
• Reassure on the clinical outcome: although T-TEER is more effective regarding the grade of residual regurgitation, the symptomatic improvement at 12 months is similar regardless of the chosen repair strategy.

Technical lexicon of the study

T-TEER (Transcatheter Tricuspid Valve Edge-to-Edge Repair): Transcatheter tricuspid valve repair technique consisting of bringing the valve leaflets together (edge-to-edge) to reduce the regurgitation orifice.

TTVA (Transcatheter Tricuspid Valve Annuloplasty): Percutaneous repair strategy targeting the tricuspid annulus, aiming to reduce its circumference to improve leaflet coaptation.

Secondary tricuspid regurgitation (Secondary TR): Tricuspid valve regurgitation generally occurring as a result of annular or right ventricular dilatation, rather than a primary structural abnormality of the leaflets.

Propensity-score matching: Rigorous statistical method used in this study to create two comparable groups (T-TEER vs TTVA) by balancing the initial clinical and anatomical characteristics of the patients.

Residual TR: Persistence of a regurgitant flow after the procedure. The study specifically measures success rates in achieving a grade ≤ 1+ or ≤ 2+.

Composite endpoint: Clinical efficacy indicator grouping, in this study, all-cause mortality and the first hospitalization for heart failure over a 12-month period.

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