T-TEER vs TTVA: Which strategy for severe secondary tricuspid regurgitation?
Severe and symptomatic tricuspid regurgitation (TR), with a prevalence reaching 4% in patients over 75 years of age, represents a growing clinical challenge. While transcatheter edge-to-edge repair (T-TEER) and transcatheter tricuspid valve annuloplasty (TTVA) have established themselves as validated therapeutic options, data directly comparing their real-world outcomes remain limited by distinct mechanistic approaches and patient selections.
This European multicentric study aims to compare the procedural efficacy, safety, and one-year clinical outcomes of these two strategies in patients suffering from severe secondary TR. Drawing on the PASTE registry (PASCAL system) and a TTVA cohort (Cardioband system), the authors analyzed 1,122 patients, of whom 111 pairs were isolated via propensity score matching (PSM) to correct for initial selection biases.
The hypothesis evaluated is twofold: to determine whether one of the techniques offers superiority in terms of sustainable reduction of TR and whether the immediate safety profile influences the medium-term clinical prognosis, including mortality and hospitalizations for heart failure.
Methodology of the comparative study
This multicentre cohort study included 1,122 consecutive patients treated between 2017 and 2024 for severe and symptomatic secondary tricuspid regurgitation (TR). Participants were divided into two groups according to the intervention technique used: transcatheter edge-to-edge repair (T-TEER with the PASCAL system, n = 882) or transcatheter tricuspid annuloplasty (TTVA with the Cardioband system, n = 240). To limit selection bias related to initial anatomical and clinical characteristics, a 1:1 propensity score matching (PSM) was performed, allowing for the isolation of 111 pairs of patients with comparable profiles.
The protocol evaluated the severity of TI according to a precise 6-grade classification:
- 0+ (none), 1+ (slight), 2+ (moderate)
- 3+ (severe), 4+ (massive), 5+ (torrential)
The endpoints included procedural success, peri-operative complications (anchor leaks, vascular lesions, major bleeding, stroke), and clinical outcome at one year. The primary composite endpoint associated all-cause mortality and the first hospitalization for heart failure. The balance of the 111 matched pairs was verified across numerous covariates, including age, sex, body mass index, NT-proBNP level, left ventricular ejection fraction (LVEF), and valvular morphology.
Procedural efficiency and reduction of tricuspid regurgitation (TR)
Propensity score-matched analysis (111 pairs) reveals technical superiority of T-TEER over TTVA in achieving minimal residual TR. At hospital discharge, T-TEER achieved significantly higher rates of TR reduction compared to TTVA.
| Evaluation criteria | T-TEER (n=111) | VAT (n=111) | P value |
|---|---|---|---|
| residual IT ≤ 1+ | 50.0 % | 34.2 % | < 0.05 |
| IT residual ≤ 2+ | 87.7 % | 67.6 % | < 0.05 |
| Réduction de l'IT ≥ 2 grades | Comparable between groups | NS | |
Beyond immediate efficacy, T-TEER has demonstrated better durability in TR reduction during follow-up. The authors note that T-TEER offers a more pronounced and stable reduction profile over time for patients with anatomical overlap eligible for both techniques.
Safety and peri-procedural complications
The safety profile represents the most striking difference between the two approaches. The overall rate of procedural complications is significantly lower with T-TEER (4.5%) than with TTVA (27.0%), with a highly significant P-value (P < 0.001). This disparity is notably explained by the technical complexity of annuloplasty (Cardioband), including risks of anchor detachment, vascular lesions at the access point, major hemorrhages, or coronary artery lesions requiring percutaneous intervention.
Clinical evolution and 1-year survival rate
Despite an initial technical superiority of T-TEER, mid-term clinical results converge. Symptomatic improvement (NYHA class) and reintervention rates at 1 year are similar between the two groups. The composite endpoint (all-cause mortality or first hospitalization for heart failure) shows no statistically significant difference:
- Freedom from the composite endpoint (T-TEER): 75.0% (95% CI: 66.8-84.1)
- Freedom from composite endpoint (TVAF): 79.8% (95% CI: 72.4-87.9)
- Statistical comparison: P = 0.408
In summary, while T-TEER stands out for its safety and immediate hemodynamic efficacy, the impact on clinical prognosis at 1 year remains equivalent to TTVA after adjustment for baseline characteristics.
Clinical analysis: technical superiority versus clinical parity
The results of this study mark a turning point in the understanding of percutaneous tricuspid interventions. Out of the 111 matched pairs, T-TEER (PASCAL system) demonstrates superior efficacy compared to TTVA for the immediate reduction of tricuspid regurgitation (TR). With 87.7% of patients achieving TR ≤ 2+ versus only 67.6% for annuloplasty (p < 0.05), the coaptation technique emerges as more technically efficient. Even more striking: the safety profile of T-TEER is significantly more favorable, with a complication rate of 4.5% compared to 27.0% for TTVA (p < 0.001).
However, a question remains for the clinician: why does this technical superiority not translate into a clinical benefit at one year? Survival rates without hospitalization for heart failure remain comparable (75.0% for T-TEER vs 79.8% for TTVA, p = 0.408). This paradox suggests either that the reduction of TR to grade ≤ 2+ constitutes a sufficient threshold for symptomatic improvement, or that the long-term benefit of annular remodeling by TTVA requires follow-up beyond 12 months to manifest itself against the immediate robustness of edge-to-edge.
Limits and perspectives
L'étude souligne les défis de l'annuloplastie directe, dont le dispositif Cardioband a été retiré du marché en 2024. Les complications procédurales plus fréquentes (lésions vasculaires, détachements d'ancres) illustrent la complexité technique de cette approche. De plus, bien que le score de propension (PSM) équilibre les cohortes, le caractère rétrospectif et le choix initial des patients basé sur l'anatomie introduisent un biais de sélection inhérent que seule une étude randomisée pourrait lever.
Summary of results
This comparative study (111 matched pairs) demonstrates a clear superiority of T-TEER (PASCAL) over TTVA (Cardioband) regarding safety, with only 4.5% complications compared to 27.0% (p < 0.001). T-TEER also ensures a more effective reduction of tricuspid regurgitation (TR ≤ 2+ in 87.7% vs 67.6%, p < 0.05), although clinical outcomes at one year (mortality and hospitalisations) are statistically comparable (p = 0.408).
In concrete terms, for the practitioner:
- Priority to T-TEER: favor this approach as a first-line treatment for eligible patients, as its safety profile is six times superior to that of annuloplasty.
- TTVA Vigilance: if direct annuloplasty is considered (via future devices), anticipate an increased risk of peri-procedural complications (bleeding, detachments) compared to edge-to-edge.
- Post-operative follow-up: maintain rigorous management of heart failure at one year, as the immediate technical superiority of T-TEER does not yet translate into a significant reduction in rehospitalizations in the medium term.
Technical Lexicon
T-TEER (Transcatheter Edge-to-Edge Repair): Tricuspid repair technique consisting of bringing two valve leaflets together according to the Alfieri principle to improve coaptation.
TTVA (Transcatheter Tricuspid Valve Annuloplasty): Percutaneous tricuspid annuloplasty via the implantation of anchors along the atrial ring, followed by cinching to reduce the annular diameter.
Atrial phenotype: Specific clinical and ultrasound profile characterized by a TAPSE >17 mm, a left ventricular ejection fraction (LVEF) ≥50% and a tenting height <10 mm.
Complex anatomy: Tricuspid valve morphology featuring more than three leaflets, complicating percutaneous repair procedures.
TRI-SCORE: Specific prognostic scoring system used to assess the risk of in-hospital mortality in patients undergoing tricuspid valve surgery.
TVARC Criteria: Standardized framework of the Tricuspid Valve Academic Research Consortium used to define and report successes and complications of tricuspid valve interventions.
Source
- Original title: Transcatheter Tricuspid Valve Annuloplasty vs Edge-to-Edge Repair
- Authors: Jennifer von Stein, Philipp von Stein, Lukas Stolz, J. Althoff, Caroline Hasse, Sebastian Rosch, Felix Rudolph, Johannes Kirchner, Bjoern Goebel, Benedikt Koell, Wolfgang Rottbauer, Tienush Rassaf, Harald Beucher, Martin Kraus, Mohammad Kassar, Tobias Geisler, Andreas Rück, Joao Ferreira-Martins, Stefan Toggweiler, Paula Sagmeister, Dirk Westermann, Thomas J. Stocker, Ludwig T. Weckbach, Michael Näbauer, Sam Dawkins, Tobias Kister, Marc Vorpahl, M H Konstandin, Peter Luedike, Mirjam Keßler, Christos Iliadis, Philipp Lauten, Christian Besler, Daniel Kalbacher, Kai Friedrichs, Muhammed Gerçek, Juan F. Granada, Philipp Lurz, Jörg Hausleiter, Mirjam G. Wild, Maria Isabel Körber, Florian Schindhelm, Tom Cahill, Kornelia Löw, Philipp Schlegel, Norbert Frey, Dominik Felbel, Stephanie Andress, Amir Abbas Mahabadi, Volker Rudolph, Leonie Ziegler, Cornelia Deutsch, Violetta Hachaturyan, Peter Bramlage, Isabela Kast, Sebastian Ludwig, Roman Pfister, Stephan Baldus, Maria I. Körber
- Publication: JACC Advances - 2026-07-22
- DOI: https://doi.org/10.1016/j.jacadv.2026.103033
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