Is transcatheter edge‑to‑edge repair (TEER) indicated for physiologic severe tricuspid regurgitation secondary to severe pulmonary hypertension from chronic thromboembolic pulmonary hypertension (CTEPH)?

TEER is NOT Indicated for Physiologic Severe TR Secondary to Severe Pulmonary Hypertension from CTEPH

In patients with severe TR secondary to severe pulmonary hypertension from CTEPH, transcatheter tricuspid valve intervention should NOT be performed until the underlying pulmonary hypertension is definitively treated with pulmonary thromboendarterectomy (PTE), as the TR is physiologic and will resolve with correction of the elevated pulmonary pressures. 1

Primary Treatment: Address the Root Cause

Pulmonary Thromboendarterectomy is the Definitive Treatment

• PTE is the treatment of choice for CTEPH and will resolve the severe pulmonary hypertension that is causing the physiologic TR 1
• Functional TR improves dramatically after successful PTE, even in patients with high pulmonary vascular resistance 2
• In patients with grade 4 (severe) TR pre-operatively, severity decreased to grade 2 in 8 patients and to grade 1 in 1 patient after PTE 2
• Tricuspid valve function returns to normal within days after PTE as a result of restoration of tricuspid annular geometry following RV remodeling 1
• Tricuspid valve repair is NOT performed during PTE because the TR resolves spontaneously with normalization of RV geometry 1

Hemodynamic Improvements After PTE

• Pulmonary artery systolic pressure decreases from 84±17 mmHg to 38±14 mmHg post-operatively 2
• Pulmonary vascular resistance decreases from 1,025±465 to 477±181 dynes·sec·cm⁻⁵ 2
• Mean pulmonary artery pressure decreases from 48±10 to 24±9 mmHg 2
• TR velocity decreases significantly from 432±53 to 197±154 cm/s 2

Why TEER is Contraindicated in This Context

Severe Pulmonary Hypertension Excludes TEER

• Current guidelines for transcatheter mitral TEER explicitly exclude patients with systolic pulmonary artery pressure >70 mmHg 1
• While these criteria apply to mitral TEER, the same physiologic principles apply to tricuspid TEER—severe pulmonary hypertension predicts poor outcomes 1
• The 2023 ACC/AHA and ESC/EACTS guidelines recommend transcatheter treatment of symptomatic secondary severe TR only in inoperable patients at specialized centers (Class IIb-C), and this weak recommendation does NOT apply when severe pulmonary hypertension is reversible 1

Physiologic TR Will Not Respond to TEER

• The TR in CTEPH is purely physiologic—caused by RV dilatation and tricuspid annular dilatation secondary to pressure overload 1
• Treating the valve without treating the underlying pulmonary hypertension is futile and does not address the disease mechanism 1
• Higher pulmonary capillary wedge pressure CV-wave height is associated with lower likelihood of clinical success after tricuspid TEER 3

Clinical Algorithm for Management

Step 1: Confirm CTEPH Diagnosis and Operability

• Perform ventilation-perfusion scanning, CT pulmonary angiography, and right heart catheterization to confirm CTEPH 1
• Refer to a specialized CTEPH center for evaluation of PTE candidacy 1
• Assess for contraindications to PTE (distal small-vessel disease without proximal thrombus) 1

Step 2: Medical Management While Awaiting PTE

• Initiate loop diuretics to manage volume overload and right-sided heart failure symptoms 4, 5
• Titrate diuretics to relieve systemic venous congestion, hepatic congestion, and peripheral edema 4
• Consider aldosterone antagonists for additive diuretic benefit 5
• Avoid overly aggressive diuresis that precipitates hypotension and worsening renal function 5

Step 3: Proceed with PTE

• PTE should be performed at an experienced center with expertise in this complex procedure 1
• Perioperative mortality is approximately 6.4% at experienced centers 1
• The most important prognostic factor is the severity of PVR elevation and the ability to lower it to normal range 1

Step 4: Reassess TR After PTE

• Perform transthoracic echocardiography 3-6 months after PTE to assess TR severity 2
• In the vast majority of cases, TR will have improved to mild or moderate 2
• If severe TR persists despite normalization of pulmonary pressures, then consider surgical tricuspid valve repair (NOT transcatheter intervention) 1

Common Pitfalls to Avoid

Do Not Perform Isolated Tricuspid Intervention

• Performing TEER on the tricuspid valve without addressing the severe pulmonary hypertension from CTEPH will fail to improve symptoms or outcomes 1
• The TR will persist or recur because the underlying hemodynamic abnormality (elevated RV pressure) remains untreated 1

Do Not Delay PTE Referral

• Patients with CTEPH should be referred urgently to a specialized center for PTE evaluation 1
• Delaying definitive treatment with PTE while attempting medical management or transcatheter interventions worsens outcomes 1
• Even patients with massive RV enlargement and severe RV dysfunction show marked improvement after successful PTE 1

Recognize When PTE is Not Feasible

• Patients with type 4 small-vessel vasculopathy (indistinguishable from WHO Group I pulmonary arterial hypertension) have the worst prognosis and surgery does not correct pulmonary hypertension 1
• In these rare cases where PTE is not feasible and severe pulmonary hypertension persists, conservative medical management is recommended rather than tricuspid intervention 4

Prognosis

Excellent Outcomes After PTE

• Survival after PTE is 75% at 6 years or more 1
• 93% of patients are in NYHA class I or II post-operatively, compared with 95% in NYHA class III or IV before surgery 1
• Of patients desiring employment, 62% who were unemployed before operation returned to work 1

Poor Outcomes Without PTE

• The combination of severe TR, cor pulmonale, and pulmonary hypertension carries a poor prognosis with 1-year mortality approaching 45.6% without definitive treatment 5