E. Donal | Tricuspid-TEER vs TTVR: 2026 update (Theory 15')

Dear colleagues, dear friends, I'm sorry that I'm not with you today to discuss in person about this important topic about the management of patients having a try speed regurgitation. Of course, we have to do and to manage the patient appropriately with the medical treatment. But on top of that, we might have also to consider an intervention. And this intervention can be a clip or a prosthesis. So a TT versus a TTVR. But of course first of all I would like to emphasize on the fact that if you are an imager when you assess a patient with a left heart valve disease when you assess a patient with a cardiammyopathy or a heart failure you really have to look at the right heart and to have views uh dedicated to the right heart looking at the air function size looking at the air size and looking also at the triricuspid rigor it is an independent prognostic marker. So the triricuspid rigger whatever the left heart disease you can have is a marker of risk uh for our patients. So you cannot let a patient go home without any significant assess without a clear assessment of the triricuspit reg. If you have a triricuspiders, you have to consider the fact that you don't have to wait too long and you might have to refer the patient to a center where the treatment of the triricuspiders can be applied. It could be surgical, it could be interventional and of course it is always medical. On top of that for the expert hard valve center they might have to do a complete echo including 3D maybe including CMR they have to do a specific complete TE they have also to do a right heart categorization and if the patient is not suitable for a Dtier we have to do a specific city for the planning of an implantation. of hypothesis. And then we have to provide to the patient a multi-disiplinary assessment including people who know about old patients, people who know about the coorbidities, people who know about heart failure, imaging, surgery and interventions of course and then we have to decide what is the best solution for any single patient. It is not a solution that we can apply to every patients without any thought. We really have to think about the management of a patient individually. And for that we can use tools the imaging tools the right heart categorization but also some scores like the tree score that is extremely helpful for the discussion. The imager has a fundamental role and the imager should assess the anatomy of the tricuspid valve which is quite complex and also to assess the mechanism of the triricco speed rigers considering that the triricus speed rigers that are primary are extremely rare. The secondary tririccoid rigers can be atrial or ventricular. If this is ventricular you have a tenting. If it is atrial there is no tenting. And of course there are patients who come with a severe symptomatic triricco speed regard with a pacemaker lead crossing the triricuspeed valve. And then the 3D assessment of the valve might help you to define if this is a triricuspid rigers associated with a pacemaker lead or if it is an triricuspid rigers induced by the pacemaker lead. So I told you you have first of all to define the disease the syndrome associated with the triricuspid rigor and according to the syndrome associated with the triricuspage you will apply the medical treatment that is mandatory to deal with the disease and then of top of that you might have to treat specifically the triricuspid regurge and you know that we have the triaminates pertileize trial that has demonstrated an effect on the quality of life on the six world test distance. I will discuss that in details. We have also the TFR trial that I have the chance to conduct demonstrating similar things and I will come back to that soon. We have the B right registry who demonstrated a clear value of the TT the physibility the safety and the efficacy as well and we have other study that we will discuss soon. First of all let me discuss about the uh TFR trial and the TFR trial is a study that has been conducted in French. I had just realized that my slide in French actually. And you see that it was demonstrated in that study using the multilan pecker uh composite endpoint that there is a clear beneficial effect of using on top of the medical treatment the tier to treat the triricuspid rigger and the beneficial effect of the ttier is clearly obvious and it has been published uh in jana. The effect of the TT on top of the medical treatment is obvious when you look at the KCCQ is obvious when you look at the change in the Minnesota living with heart failure score is obvious when you look at the six mal test distance and also it has been published in ESC heart failure uh this study dedicated to the uh clinical uh quality of life and then you have the trial luminina trial that has demonstrated things that have some similarities with the trif that I conducted in France and you see that triuminate at one year followup like trif demonstrated a significant beneficial effect of the TT on top of the medical treatment but it was driven by the KCCQ so by the quality of life and not by the risk of death and not by the risk of hospitalization for heart failure. But the beauty of these two studies trif and triuminate is that the beneficial effect that we observe that one year followup is clearly associated with the quality of the control of the triricuspid rigor after the correction of the triricuspid rigor by tt. So you see that there is a linear relationship between the quality of the treatment that we apply to the patients and the change in the quality of life. The same has been demonstrated with the six mal test distance and also the beauty of ttier is that it is an extremely safe intervention. The risk of death is new uh is close to zero. The risk is just that sometimes we cannot achieve a good result. Sometimes we can have SLDA but this risk of SLDA nowadays is about 5%. So it's extremely low. So the TT is an effective treatment and it is extremely safe. What about the ad end points? And that's the issue that we face nowadays and we have this triilum pivotal trial with a follow-up that has been conducted at two years followup. But in triilinate the physician saw every single patient at one year and at one year if the patient was considered as too sick it was possible to treat the patient. And as you can see half of the patients have been treated after one year followup with the ttier. And the point is that there is a lot of crossover. So it's very difficult to interpret the data that we have at two-year follow-up. But still you see that when you treat the patients after one year of follow-up in the medical harm there is a clear clinical benefit uh of the TT and you see that the patient that have been treated after one year followup got an improvement in the quality of life that is close to the one that has been achieve for the patient that have been treated one year earlier also it has been demonstrated despite the fact that there was 50 50% of crossover that there is an effect of the TT on the risk of hospitalization for heart failure and this risk is significantly less in patient that have been treated after one year followup. But of course it's difficult to understand and to to to explain because half of the patient got a TT after one year followup and this 50% of patients that have been treated after one year followup are the most severe patients and that's complicated and actually when you look at this data it has been think or I don't know how can I say that these patients who have been treated after one year followup have been the most severe and then actually the effect that has been demonstrated at two-year follow-up about the risk of hospitalization for heart failure is probably downgraded by the fact that half of the population has been treated by TT after one year. So there is a clear benefit about heart failure hospitalization at two-year follow-up despite the fact that in the medical arm we just have the 50% of patients that are the less severe that have been included uh at the very beginning. So it means that probably yes we have a crossover but this crossover has been applied to the most severe patients and despite the fact that this most severe patient have been treated after one year follow-up still there is an effect on hospitalization at two-year follow-up. So this is quite interesting. There is another study that I have to discuss. This is the um trial and the trion trial is dedicated to the evok prosthesis. So this is the TTVR. So it is a prostthesis that is quite easy to implant and uh the value of that TTVR is that there is an effect of this correction of the T trios speed rigers by the prosthesis. But this effect is exactly the one that we got with TT. But there is an effect that is similar to Gtier. But the risk of the intervention is not exactly the same because you see on that slide that the risk of a complication is much higher after TTVR than after TT. The risk of pacemaker implantation is about 24% or 25% of the patients that have been included in treat and also there is a risk of severe bleeding that is much higher that the ones that we saw with TT but it is clear that when you implant the prosthesis there is no more triricuspid rigers afterwards and this is already an efficient prostthesis. But this efficacy on the degree of TR is associated with a beneficial effect on the quality of life on the six mal test distance as we saw with TT without any significant effect on the risk of hospitalization or death at one year followup. So we have some kind of similar results with TTVR that the ones we got with TT but with a much higher risk of the intervention uh when we do this kind of treatment. So it means that nowadays we have to assess the patients as soon as we can. We use TT Te right categorization multidisciplinary evaluation and if the patient has an anatomy that is suitable with TT we start with a TT tier and we try to deal with the disease with the Tier and if the patient is unsuitable for TTR because of the anatomy of the valve because of the severity of the gap then we discuss the TTVR and we do a TT and if the patient is suitable for TTVR then we implant a TTVR. So there are patients in the green zone that are extremely suitable for TT. There are patient in the yellow zone that are suitable for TT and then we prefer to apply the TTR treatment in these patients. There are patients where the anatomy is unsuitable for TT and then we do a TTVR. And some patient are too frail, too fragile and then in that patients we just do a medical treatment because we believe that it is futile to treat the triricuspiders. According to the guidelines it has been demonstrated that if you have a left side surgery to do then you can consider the treatment of the triricuspeed valve on top of the left side surgery. As you can see if you but you have to be careful and you have to have some degree of triricusped rigor. You cannot treat nowadays a patient just because the the triricuspid ananalus is dilated. You have to combine the presence of a tr and a delightation of the triricuspid ananus. If you have an isolated TR, you can treat the patients who are symptomatic without any significant AV dysfunction by surgery. If the patient has a tree score that is suitable for that patient is asytomatic, you can consider surgery if there is a dilation of the AV or a decrease in AV function on top of the triricuspid regge. And of course if the patient is suitable for surgery and of course we also have this TT and the TTVR and the indication is 2 AAA. So it's quite a high level of evidence and a high level of recommendation for patient who are symptomatic with a severe secondary triricuspid regurgitation and then if the patient is unsuitable for surgery these perccutinous treatments can be considered with a high level of evidence. So we have to be clear to refer earlier the patients to assess completely this patient in referral centers. If the patient have a left side surgery then a conccomittant can be considered. If there is a rig and a try to speed analous deitation. If the patient is unsuitable for surgery then we can consider TTR first and then TTVR. if the patient is unsuitable for TT and of course this is something that we apply on top of the optimization of the medical treatment always on top of the optimization of the medical treatment. So the triricuspid is not a benign disease. We need for an earlier recognition. We need to refer patient to heart valve dise air valve centers uh that are dedicated to these kind of diseases. Imaging is fundamental for the diagnosis for the prognosis and for the procedural planning. The fact that we have now these transcator therapies change completely the field and TT VR and TT are really new devices that are extremely promising. We still need some for more evidences about who are the patient who will take the most advantage of the treatment and who are the patients that shouldn't be treated. But a lot of studies are going on. If you want to learn more, you can see that we will present at the SEC in two weeks the result after two years of followup of TrifR. And the beauty of the study is that it's an academic study and then we have data that has been collected without any crossover. So we have for the first time the capability to show the beneficial effect or not of the TT on top of medical treatment after two years of followup in these kind of patients. So please follow the ACC and you will see. Thank you very much. >> Okay. I don't know if Professor Dal is available for questions. Probably not. he's in uh the operating theater or something. Um it's obviously a very very important development which the presence of the evoke valve and opens a new a new page in the treatment of patients with severe triricospitation. One thing that um is of concern when we are facing choosing between tear and a voc valve is with tear you are left with mild probably moderate triricospit good station. there's never no tririccos regation as opposed to with the evoke valve that you are left with no tririccos regation and that's important for the right vent that's why and that's where we need uh professor v kovac's ai to see whether the tri with the right ventricle will be able to cope with the sudden increase of um of overload after abolishing triricosid registration because if you have a a right vent which is already suffering if you abolish tricosid regurgitation you either need a lot ofotropes in ICU or your patient dies. So it is probably better to leave the patient with some triricospit regurgitation applying a tear. So these are important new considerations as uh progress uh evolves in uh and having more therapeutic options for our patients with severe tricos regurgitation. Uh Luigi shall we start? We have about 15 minutes for discussion.