Lukas Stolz, Karl‐Patrik Kresoja, Jennifer von Stein, Vera Fortmeier, Christoph Pauschinger, Wolfgang Rottbauer, Mohammad Kassar, Bjoern Goebel, Paolo Denti, P A Achouh, Tienush Rassaf, Manuel Barreiro-Perez, Peter Boekstegers, Andreas Rück, Monika Zdanyte, M Adamo, Flavien Vincent, Philipp Schlegel, Sebastian Rosch, Mirjam G. Wild, Christian Besler, Stefan Toggweiler, Stephanie Brunner, Julia Grapsa, Tiffany Patterson, H.‐G. Thiele, Tobias Kister, Giuseppe Tarantini, Giulia Masiero, Hannah Kempton, Marco De Carlo, Cristina Giannini, Fabian Voss, Amin Polzin, A Popolo Rubbio, F Bedogni, Thorald Stolte, Thomas Nestelberger, Tomas Benito-Gonzalez, Enrique Sánchez-Muñóz, Martijn G. H. Vrijkorte, Martin J. Swaans, Mathias H. Konstandin, Eric Van Belle, Marco Metra, Tobias Geisler, Rodrigo Estévez-Loureiro, Amir Abbas Mahabadi, Nicole Karam, Francesco Maisano, Philipp Lauten, Mirjam Kessler, Daniel Kalbacher, Volker Rudolph, C Iliadis, P H I L I P Lurz, F Praz, Jörg Hausleiter, Philipp M. Doldi, Ludwig T. Weckbach, Thomas J. Stocker, Julia Novotny, Kaspar Volz, Cand Med, Katalin Berschiminski, Cand Med, Karl-Philip Rommel, Ralph Stephan von Bardeleben, Roman Pfister, Stephan Baldus, Philipp von Stein, Muhammed Gerçek, Felix Rudolph, Hazem Omran, Sebastian Ludwig, Benedikt Koell, Leonhard‐Moritz Schneider, Dominik Felbel, Carsten Salomon, Harald Lapp, Quentin de Baynast, Alain Berrebi, Florian Schindhelm, Berenice Caneiro-Queija, Julio Echarte-Morales, Andreas Goldschmied, Edoardo Pancaldi, Elisa Pezzola, Mauro Massussi, Laura Lupi, Natacha Rousse, Samy Aghezzaf, Norbert Frey, Martin Kraus, Dirk Westermann, Leonie Ziegler, Charlotte Wolff, Federico Arturi, Alessandro Sticchi, Matteo Mazzola
BACKGROUND: According to the 2025 ESC/EACTS guidelines for the management of valvular heart disease, transcatheter tricuspid valve interventions (TTVI) have received a Class IIa recommendation (Level of Evidence: A) for the treatment of patients with severe symptomatic tricuspid regurgitation. However, in patients with severe left ventricular dysfunction (LVD) or right ventricular dysfunction (RVD) or precapillary pulmonary hypertension (pcPH), optimal medical therapy (OMT) is preferred because of the potential risk for futility. OBJECTIVES: The aim of this study was to evaluate clinical and symptomatic outcomes in such "OMT candidate" patients. METHODS: Using data from EuroTR (European Registry of Transcatheter Repair for Tricuspid Regurgitation), guideline-based thresholds for LVD, RVD, and pcPH were applied to patients undergoing tricuspid valve transcatheter edge-to-edge repair (T-TEER). Patients meeting ≥1 exclusion criterion ("OMT candidates") were compared with those meeting current recommendations ("TTVI appropriate") regarding NYHA functional class improvement and 2-year survival free from heart failure hospitalization (HFH). RESULTS: Among 1,626 T-TEER patients, 213 (13.1%) met ≥1 exclusion criterion (4.2% of those with LVD, 6.8% of those with RVD, and 3.6% of those with pcPH). Severe LVD, RVD, and pcPH were each associated with significantly lower 1-year HFH-free survival (LVD, 54.6% vs 72.9% [P < 0.001]; RVD, 59.0% vs 73.2% [P = 0.003]; pcPH, 56.2% vs 73.4% [P = 0.021]; median survival follow-up 446 days [Q1-Q3: 192-805 days]). Despite higher NYHA functional class at baseline and follow-up, the rate of ≥1-class improvement was comparable across subgroups (LVD, 51.1% vs 59.4% [P = 0.25]; RVD, 59.7% vs 59.0% [P = 0.90]; pcPH, 51.3% vs 59.4% [P = 0.31]). Overall, "OMT candidates" had lower HFH-free survival than "TTVI-appropriate" patients (58.7% vs 74.3%; P < 0.001) but showed comparable symptomatic relief (≥1 NYHA functional class in 56.2% vs 59.5%; P = 0.68). CONCLUSIONS: T-TEER may provide symptomatic benefit in selected high-risk patients with severe LVD, RVD, or pcPH. In the absence of randomized evidence, multidisciplinary evaluation at experienced heart valve centers remains essential to balance potential benefit against procedural futility. Further studies are warranted to refine patient selection and optimize outcomes in this challenging cohort.