ACC 2025 Expert Consensus on Severe Tricuspid Regurgitation (TR) – Clinical Summary
ACC 2025 Expert Consensus on Severe Tricuspid Regurgitation (TR) – Clinical Summary
Source : 2025 ACC Consensus on Severe Tricuspid Regurgitation. J Am Coll Cardiol, Sept 22, 2025.
Keynotes :
1. Patient Identification and Indications
• Primary indication: patients with severe symptomatic TR (NYHA II–IV) who remain symptomatic despite optimal medical therapy (OMT).
• Most cases are secondary TR, due to:
• Left-sided valve disease or heart failure.
• Long-standing atrial fibrillation → right atrial enlargement and annular dilation.
• Pulmonary hypertension with RV remodeling.
• Pacemaker/ICD leads: highlighted because device leads can directly cause TR by impeding leaflet motion or tethering the valve.
• Compared with Mitral TEER: patient selection for tricuspid TEER is less restrictive, reflecting unmet need and safety of new catheter devices. Many TR patients may be considered even at intermediate surgical risk, unlike the stricter criteria for mitral interventions.
2. Evaluation
• First-line imaging: transthoracic echocardiography (TTE).
• Advanced imaging (CT, MR):
• Assess annular dilation (common in secondary TR).
• Evaluate RV and RA size, RV systolic function, and leaflet tethering(The severity of leaflet pulling, assessed by imaging (coaptation gap), is a key determinant of TEER feasibility).
• Plan for device sizing and implantation strategy.
• Key concept: annular dilation is a hallmark of secondary TR but may not be present in primary TR (recognizing this mechanism guides therapy: secondary TR often treated with catheter-based repair/replacement, while primary TR may require surgery).
3. Decision-Making
• Decisions are made by a multidisciplinary Heart Team (imaging specialists, interventionalists, surgeons).
• Factors considered:
• Symptom burden.
• Surgical risk profile (low vs. intermediate vs. high).
• Anatomy (annulus size, coaptation gap, RV function, presence of device leads).
4. Treatment Options
• Medical therapy:
• Loop diuretics to manage congestion.
• Control atrial fibrillation.
• Manage pulmonary hypertension when possible.
• Catheter-based interventions:
• T-TEER (TriClip, Abbott): edge-to-edge leaflet repair.
• TTVR (Evoque, Edwards): full transcatheter valve replacement.
• Both devices have FDA approval (2024–2025) and CMS coverage in the U.S. → expanded access.
• Surgery:
• Reserved for lower-risk patients or those already undergoing left-sided valve surgery.
• Still underused compared with aortic and mitral surgery because:
1. Patients often present late with advanced RV dysfunction → outcomes are poor.
2. Historically limited evidence supporting early tricuspid surgery.
3. Higher operative risk due to comorbidities (HF, AF, PH).
4. Traditionally performed only when combined with mitral/aortic surgery.
5. Rapid growth of safer catheter-based options has further reduced surgical referrals.
5. Special Considerations
• Pacemaker leads: important cause of TR; management may involve lead revision or device-based repair/replacement.
• Cor pulmonale / COPD:
• Not all patients with cor pulmonale qualify.
• End-stage pulmonary hypertension with fixed RV failure is unlikely to benefit.
• If COPD causes functional TR that is severe and symptomatic despite OMT, catheter therapy may be considered.
• Post-MI (RV infarction): may result in secondary TR; intervention considered if TR remains severe and symptomatic after optimized HF/ischemia therapy.
• Elderly and frail patients: catheter-based options offer less invasive alternatives.
• Right ventricular dysfunction:
• Mild–moderate: intervention works best before severe irreversible RV failure.
• Severe but potentially reversible: suggested if RV function improves after decongestion/afterload reduction, or if advanced imaging shows preserved contractile reserve without extensive fibrosis (e.g., cardiac MRI without late gadolinium enhancement).
• Severe and irreversible: usually considered futility; outcomes are poor regardless of intervention.
6. Mitral vs. Tricuspid TEER – Key Differences
• Common features:
• Both require persistent symptoms despite OMT, Heart Team evaluation, and suitable anatomy.
• MitraClip (Mitral TEER):
• Primary MR: indicated for high/prohibitive surgical risk.
• Secondary MR: requires strict COAPT-like criteria (LVEF 20–50%, LVESD ≤70 mm, PASP ≤70 mmHg, central jet).
• Strong evidence for reduced HF hospitalizations and mortality.
• TriClip (Tricuspid TEER):
• Indicated for severe symptomatic TR (usually secondary) despite OMT.
• Fewer anatomic and functional restrictions compared with MitraClip.
• Considered in patients with intermediate or high surgical risk, not just prohibitive risk.
• Clinical benefit is mainly symptom relief and improved functional capacity; survival benefit less established than in mitral disease.
7. Follow-Up
• Clinical monitoring: symptoms, exercise tolerance, quality of life.
• Imaging: periodic echocardiography ± CT/MR to assess residual TR, RV function, and device durability.
• Lifelong surveillance is required as the field and devices continue to evolve.
8. Key Clinical Takeaways
1. Indication: severe symptomatic TR despite OMT → catheter therapy should be considered.
2. Secondary TR is the main target group (left-sided disease, AF, pulmonary hypertension).
3. Pacemaker/ICD leads are a recognized cause and require special evaluation.
4. Annular dilation is central to secondary TR and must be measured for planning.
5. Criteria for TriClip/TTVR are less restrictive than for MitraClip; even intermediate-risk patients may qualify.
6. Not all cor pulmonale/COPD qualify; interventions are reasonable only when TR itself is severe and symptomatic, not when PH is end-stage.
7. Surgery is underused due to late referral, high operative risk, and the rise of catheter alternatives.
8. TEER/TTVR mainly improve symptoms and function; survival benefit is stronger in mitral disease.
