Letter: Balancing, timing, and efficiency in tricuspid TEER

We read with great interest the study by Baldus et al “Transcatheter valve repair of tricuspid regurgitation: 1-year outcomes from the TriCLASP study”, reporting the 1-year outcomes of tricuspid transcatheter edge-to-edge repair (T-TEER) using the PASCAL system (Edwards Lifesciences) in patients with significant tricuspid regurgitation (TR)1. The authors should be commended for demonstrating high technical success and encouraging clinical improvement in this challenging patient cohort. However, certain aspects of the study warrant further discussion.

Firstly, the substantial discordance between site and core lab TR grading, where almost one-quarter of enrolled patients had ≤moderate TR, as graded by the core lab, raises an important question: could these “moderate” patients still benefit from intervention, much like the early transcatheter aortic valve implantation experience, where treating severe aortic stenosis before advanced symptom onset improved outcomes2? If moderate TR patients are indeed symptomatic or demonstrate early right heart remodelling, earlier T-TEER could preserve ventricular function and prevent irreversible damage. Conversely, without randomised evidence, inclusion of such patients risks overestimating the benefit of the intervention if their natural course is more benign. As a...