T-TEER: Beyond Traditional Pulmonary Hypertension Thresholds

Significant tricuspid regurgitation (TR) is associated with progressive functional deterioration, heart failure (HF) hospitalizations, and increased mortality. In recent years, transcatheter tricuspid edge-to-edge repair (T-TEER) has become the most widely used percutaneous strategy in patients at high surgical risk. However, optimal patient selection remains challenging, particularly in those with pulmonary hypertension or advanced hemodynamic compromise.

Although current guidelines recommend right heart catheterization as part of the preprocedural assessment, there is limited evidence regarding which invasive parameters truly carry prognostic value after tricuspid intervention. In this context, a subanalysis of the EuroTR registry evaluated the impact of baseline invasive hemodynamics on early and late clinical outcomes following T-TEER.

The multicenter registry included patients treated with isolated T-TEER between 2016 and 2024 across 26 European centers. A total of 711 patients with invasive hemodynamic assessment prior to the procedure were analyzed.

The late clinical endpoint was the composite of all-cause mortality or HF hospitalization at 2 years. In addition, a patient-centered endpoint at 6 months was defined as a composite of mortality, HF hospitalization, or persistence/worsening of NYHA functional class IV.

The population had a mean age of 81 years; 93% had atrial fibrillation and 58% had a history of HF hospitalization. Left ventricular ejection fraction was 55%. Baseline mean pulmonary artery pressure (mPAP) was 27 mmHg and pulmonary capillary wedge pressure (PCWP) was 17 mmHg.

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Freedom from death or HF hospitalization at 2 years was 63%. Threshold optimization analysis identified specific prognostic values associated with clinical events: mPAP ≥32 mmHg, PCWP ≥20 mmHg, and pulmonary vascular resistance (PVR) ≥5 Wood units.

PCWP showed the most consistent prognostic performance. A PCWP ≥20 mmHg was independently associated with early clinical deterioration at 6 months (HR 2.77; 95%CI 1.47-5.28; p<0.001) and with the composite of death or HF hospitalization at 2 years (HR 1.75; 95%CI 1.03-3.02; p=0.04).

Patients with elevated mPAP or PCWP experienced a smaller magnitude of symptomatic improvement after the procedure, although they still maintained a significant reduction in functional class during follow-up.

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Furthermore, patients with two or more parameters above the identified thresholds had the worst clinical outcomes, reinforcing the value of comprehensive hemodynamic assessment rather than isolated interpretation of a single variable.

Conclusions: T-TEER: Invasive Hemodynamics Redefine Prognostic Risk

This subanalysis of the EuroTR registry demonstrates that invasive hemodynamics continue to provide relevant prognostic information in patients undergoing T-TEER. The thresholds associated with adverse events were higher than those proposed by current guidelines for the diagnosis of pulmonary hypertension, suggesting that risk stratification in advanced TR requires population-specific criteria.

Original Title: Invasive Hemodynamics and Risk Stratification in T-TEER: Moving Beyond ESC Thresholds – EuroTR Registry Insights.

Reference: Masiero G, Arturi F, Ceni S, Panza A, Kresoja KP, von Stein J, Fortmeier V, Koell B, Rottbauer W, Kassar M, Goebel B, Denti P, Achouh P, Rassaf T, Barreiro-Perez M, Boekstegers P, Rück A, Zdanyte M, Adamo M, Vincent F, Schlegel P, Rosch S, Wild MG, Besler C, Toggweiler S, Brunner S, Grapsa J, Patterson T, Thiele H, Kister T, Sticchi A, De Carlo M, Voss F, Polzin A, Popolo Rubbio A, Bedogni F, Stolte T, Nestelberger T, Benito-González T, Sánchez-Muñóz E, Konstandin MH, Van Belle E, Metra M, Geisler T, Estévez-Loureiro R, Mahabadi AA, Karam N, Maisano F, Lauten P, Praz F, Kessler M, Kalbacher D, Rudolph V, Iliadis C, Lurz P, Hausleiter J, Stolz L, Tarantini G; EuroTR Investigators. Invasive Hemodynamics and Risk Stratification in T-TEER: Moving Beyond ESC Thresholds – EuroTR Registry Insights. Circ Cardiovasc Interv. 2026 Jan;19(1):e015964. doi: 10.1161/CIRCINTERVENTIONS.125.015964. Epub 2025 Nov 14. PMID: 41235431; PMCID: PMC12825785.