JACC: CARDIOVASCULAR INTERVENTIONS VOL. 16, NO.

6, 2023

ª 2023 PUBLISHED BY ELSEVIER ON BEHALF OF THE

AMERICAN COLLEGE OF CARDIOLOGY FOUNDATION

NEW RESEARCH PAPER

STRUCTURAL

Prognostic Value of Tricuspid Valve

Gradient After Transcatheter
Edge-to-Edge Repair
Insights From the TriValve Registry

Augustin Coisne, MD, PHD,a,b,c,* Andrea Scotti, MD,a,b,* Maurizio Taramasso, MD,d Juan F. Granada, MD,b
Sebastian Ludwig, MD,a,b,e Josep Rodés-Cabau, MD,f Philipp Lurz, MD, PHD,g Jörg Hausleiter, MD,h Neil Fam, MD,i
Susheel K. Kodali, MD,j Alberto Pozzoli, MD,k Hannes Alessandrini, MD,l Luigi Biasco, MD,m,n Eric Brochet, MD,o
Paolo Denti, MD,p Rodrigo Estevez-Loureiro, MD,q Christian Frerker, MD,r Edwin C. Ho, MD,a Vanessa Monivas, MD,s
Georg Nickenig, MD,t Fabien Praz, MD,u Rishi Puri, MD, PHD,v Horst Sievert, MD,w Gilbert H.L. Tang, MD, MSC, MBA,x
Martin Andreas, MD, PHD,y Ralph Stephan Von Bardeleben, MD,z Karl-Philipp Rommel, MD,g
Guillem Muntané-Carol, MD,f Mara Gavazzoni, MD,d Daniel Braun, MD,h Edith Lubos, MD,e Daniel Kalbacher, MD,e,aa
Kim A. Connelly, MD,i Jean-Michel Juliard, MD,o Claudia Harr, MD,l Giovanni Pedrazzini, MD,n,bb
François Philippon, MD,f Joachim Schofer, MD,l Holger Thiele, MD,g Matthias Unterhuber, MD,g
Dominique Himbert, MD,o Marina Ureña Alcázar, MD, PHD,o Mirjam G. Wild, MD,u Ulrich Jorde, MD,a
Stephan Windecker, MD,u Francesco Maisano, MD,p Martin B. Leon, MD,b,j Rebecca T. Hahn, MD,b,j Azeem Latib, MDa

ABSTRACT

BACKGROUND Data regarding the impact of the tricuspid valve gradient (TVG) after tricuspid transcatheter edge-to-
edge repair (TEER) are scarce.

OBJECTIVES This study sought to evaluate the association between the mean TVG and clinical outcomes among pa-
tients who underwent tricuspid TEER for significant tricuspid regurgitation.

METHODS Patients with significant tricuspid regurgitation who underwent tricuspid TEER within the TriValve (Inter-
national Multisite Transcatheter Tricuspid Valve Therapies) registry were divided into quartiles based on the mean TVG at
discharge. The primary endpoint was the composite of all-cause mortality and heart failure hospitalization. Outcomes
were assessed up to the 1-year follow-up.

RESULTS A total of 308 patients were included from 24 centers. Patients were divided into quartiles of the mean TVG
as follows: quartile 1 (n ¼ 77), 0.9  0.3 mm Hg; quartile 2 (n ¼ 115), 1.8  0.3 mm Hg; quartile 3 (n ¼ 65), 2.8 
0.3 mm Hg; and quartile 4 (n ¼ 51), 4.7  2.0 mm Hg. The baseline TVG and the number of implanted clips were
associated with a higher post-TEER TVG. There was no significant difference across TVG quartiles in the 1-year composite
endpoint (quartiles 1-4: 35%, 30%, 40%, and 34%, respectively; P ¼ 0.60) or the proportion of patients in New York
Heart Association class III to IV at the last follow-up (P ¼ 0.63). The results were similar after adjustment for clinical and
echocardiographic characteristics (composite endpoint quartile 4 vs quartile 1-quartile 3 adjusted HR: 1.05; 95% CI: 0.52-
2.12; P ¼ 0.88) or exploring post-TEER TVG as a continuous variable.

CONCLUSIONS In this retrospective analysis of the TriValve registry, an increased discharge TVG was not significantly
associated with adverse outcomes after tricuspid TEER. These findings apply for the explored TVG range and up to the
1-year follow-up. Further investigations on higher gradients and longer follow-up are needed to better guide the
intraprocedural decision-making process. (J Am Coll Cardiol Intv 2023;16:706–717) © 2023 Published by Elsevier on
behalf of the American College of Cardiology Foundation.

ISSN 1936-8798/$36.00 https://doi.org/10.1016/j.jcin.2023.01.375

JACC: CARDIOVASCULAR INTERVENTIONS VOL. 16, NO. 6, 2023 Coisne et al 707
MARCH 27, 2023:706–717 Impact of Tricuspid Valve Gradient After TEER

T ricuspid regurgitation (TR) is a highly preva- TriValve (International Multisite Trans- ABBREVIATIONS

lent valvular heart disease and is associated catheter Tricuspid Valve Therapies; AND ACRONYMS
1-3
with adverse long-term clinical outcomes. NCT03416166) registry.
HF = heart failure
In light of the rarely performed isolated surgery,4,5
transcatheter tricuspid valve intervention (TTVI) has METHODS MR = mitral regurgitation

Q = quartile
emerged as a safe and effective therapeutic option
for selected patients with symptomatic TR and high STUDY POPULATION. The details of the Tri- ROC = receiver-operating

6-8 Valve registry have been described previ- characteristic

surgical risk. Among TTVI, transcatheter edge-to-
edge repair (TEER) is the most widespread technique ously.16 Briefly, the TriValve registry TEER = transcatheter edge-to-
edge repair
that results in significant TR reduction and clinical included patients with symptomatic TR who
TR = tricuspid regurgitation
improvement.7,9,10 Leaflet approximation in TEER is underwent TTVI across 24 centers in Europe
and North America. All patients had symp- TTVI = transcatheter tricuspid
associated with valve area reduction and increasing valve intervention
transvalvular gradients, with the latter also being tomatic heart failure (HF) and significant
TV = tricuspid valve
observed in cases of significant residual TR. This he- TR $2þ. Patients were referred to the registry
TVG = tricuspid valve gradient
modynamic effect is particularly relevant in cases of by local investigators and were deemed at
small valve areas or the need for multiple clips to prohibitive risk by the local interdisciplinary heart
minimize the residual regurgitation. Whether the team. The Institutional Review Board at each
resultant mean valve gradient has an impact on clin- participating site approved the study protocol,
ical outcomes is of interest to guide TEER operators and informed written consent for participation was
on the balance between aiming at the minimal resid- provided by all patients. For the purpose of this
ual regurgitation grade or avoiding increased valvular study, all patients who underwent tricuspid TEER
gradients. Although the clinical significance of the were analyzed. The included patients were divided
mean mitral valve gradient after TEER in patients into 4 groups based on the quartile (Q) (Q1, Q2,
with severe mitral regurgitation (MR) has been Q3, and Q4) distribution of the mean TVG on
explored already, 11-14
there are less data regarding discharge echocardiography.
the impact of the tricuspid valve gradient (TVG) DEFINITIONS. The TVG was measured from contin-
15
after TEER for severe TR. In this setting, we uous wave Doppler of the tricuspid inflow by tracing
sought to explore the association between the mean the entire forward flow contour from the right
TVG at discharge and outcomes among patients ventricular–focused views on 3 consecutive beats
who underwent tricuspid TEER within the whenever available (5 consecutive beats if the patient

From the aMontefiore-Einstein Center for Heart and Vascular Care, Montefiore Medical Center, Albert Einstein College of Medi-
cine, Bronx, New York, USA; bCardiovascular Research Foundation, New York, New York, USA; cUniversitè Lille, Inserm, CHU
Lille, Institut Pasteur de Lille, U1011–EGID, Lille, France; dHeart Center Hirslanden Zürich, Zürich, Switzerland; eDepartment of
Cardiology, University Heart and Vascular Center, Hamburg, Germany; fQuebec Heart and Lung Institute, Laval University,
Quebec City, Quebec, Canada; gHeart Center Leipzig at University of Leipzig and Leipzig Heart Institute, Leipzig, Germany;
h
Medical Clinic and Polyclinic I, University Hospital of Munich, Munich, Germany; iDivision of Cardiology, Toronto Heart Center,
St. Michael’s Hospital, Toronto, Ontario, Canada; jDivision of Cardiology, Columbia University Medical Center-NewYork Presby-
terian Hospital, New York, New York, USA; kDivision of Cardiac Surgery, Cardiocentro Ticino Institute, Ente Ospedaliero Canto-
nale, Lugano, Switzerland; lAsklepios Clinic St. Georg, Hamburg, Germany; m
Azienda Sanitaria Locale Torino 4, Ciriè, Italy;
n
Department of Biomedical Sciences, University of Italian Switzerland, Lugano, Switzerland; oDivision of Cardiology, Bichat
Hospital, Paris, France; pDivision of Cardiology and Department of Cardiac Surgery, San Raffaele University Hospital, Milan, Italy;
q
Interventional Cardiology Clinic, University Hospital Alvaro Cunqueiro, Vigo, Spain; rUniversity Heart Center, Schleswig-Holstein
University, Lübeck, Germany; sDivision of Cardiology, Puerta de Hierro University Hospital, Madrid, Spain; tDivision of Cardiol-
ogy, Bonn University Hospital, Bonn, Germany; uDivision of Cardiology, Inselspital, Bern University Hospital, Bern, Switzerland;
v
Department of Cardiovascular Medicine, Cleveland Clinic Foundation, Cleveland, Ohio, USA; wDivision of Cardiology, Cardio-
vascular Center Frankfurt, Frankfurt am Main, Germany; xDepartment of Cardiovascular Surgery, Mount Sinai Health System,
New York, New York, USA; yDepartment of Cardiac Surgery, Medical University of Vienna, Vienna, Austria; zDivision of Cardi-
ology, University Medical Center, Mainz, Germany; aaGerman Center for Cardiovascular Research, Partner Site Hamburg/Luebeck/
bb
Kiel, Germany; and the Division of Cardiology, Istituto Cardiocentro Ticino, Ente Ospedaliero Cantonale, Lugano, Switzerland.
*Drs Coisne and Scotti contributed equally to this work and are co-first authors.
Thomas Modine, MD, served as Guest Editor for this paper. Lars Søndergaard, MD, served as Guest Editor-in-Chief for this paper.
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’
institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information,
visit the Author Center.

Manuscript received October 24, 2022; revised manuscript received January 24, 2023, accepted January 26, 2023.
708 Coisne et al JACC: CARDIOVASCULAR INTERVENTIONS VOL. 16, NO. 6, 2023

Impact of Tricuspid Valve Gradient After TEER MARCH 27, 2023:706–717

C E N T R A L IL L U ST R A T I O N Postprocedure Gradient 1-Year Outcomes

Post-TEER Tricuspid Valve Gradients and Outcomes

From the TriValve Registry, N = 308

A Mean Tricuspid Valve Gradient by Quartiles

7

6
Tricuspid Valve Gradient (mm Hg)

2 4.7
2.8

1 1.8
0.9
0
Q1 Q2 Q3 Q4
(n = 77) (n = 115) (n = 65) (n = 51)

B Death or HF Hospitalization
100%
or HF Hospitalization
Freedom From Death

75% 70%
66%
65%
60%
50%

25%

Overall Log-Rank P = 0.60

0%
0 3 6 9 12
Months After Index Procedure
No. at risk:
Quartile 1 77 46 33 23 14
Quartile 2 115 68 52 40 31
Quartile 3 65 37 27 18 12
Quartile 4 51 29 23 16 14
Coisne A, et al. J Am Coll Cardiol Intv. 2023;16(6):706–717.

(A) The mean (SD) of post–transcatheter edge-to-edge repair (TEER) tricuspid valve gradient (TVG). (B) Kaplan-Meier analysis of 1-year
freedom from death or heart failure (HF) hospitalization showing no difference across quartiles of post-TEER TVG. Q ¼ quartile.
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 16, NO. 6, 2023 Coisne et al 709
MARCH 27, 2023:706–717 Impact of Tricuspid Valve Gradient After TEER

T A B L E 1 Baseline Characteristics According to Post-TEER TVG Quartiles

Overall Quartile 1 Quartile 2 Quartile 3 Quartile 4

(N ¼ 308) (n ¼ 77) (n ¼ 115) (n ¼ 65) (n ¼ 51) P Value

Age, y 76.4  9.2 77.8  9.0 76.5  9.2 76.0  9.6 74.9  9.2 0.48
Men 136 (44.2) 35 (45.5) 54 (47.0) 27 (41.5) 20 (39.2) 0.78
BMI, kg/m2 26.1  4.9 26.1  4.2 25.7  4.5 27.2  5.8 25.4  5.8 0.37
Diabetes 85 (27.7) 19 (24.7) 29 (25.4) 23 (35.4) 14 (27.5) 0.46
COPD 71 (23.1) 18 (23.4) 20 (17.4) 17 (26.2) 16 (31.4) 0.22
Atrial fibrillation 189 (61.8) 49 (64.5) 67 (58.8) 42 (64.6) 31 (60.8) 0.82
Prior MI 49 (15.9) 16 (20.8) 21 (18.3) 7 (10.8) 5 (9.8) 0.21
PM/ICD 87 (28.3) 23 (30.3) 25 (21.7) 22 (33.8) 17 (33.3) 0.24
Ascites 63 (22.3) 9 (13.2) 26 (23.6) 15 (25.4) 13 (28.9) 0.19
Peripheral edema 207 (72.9) 42 (60.9) 85 (77.3) 44 (74.6) 36 (78.3) 0.08
Previous RV failure 185 (68.2) 43 (64.2) 76 (80.0) 37 (67.3) 29 (69.1) 0.11
Previous left-side valve intervention 68 (22.1) 13 (16.9) 18 (15.7) 18 (27.7) 19 (37.3) <0.01
NYHA functional class III-IV 277 (91.1) 67 (87.0) 107 (93.0) 56 (91.8) 47 (92.2) 0.53
TR etiology 0.14
Functional 266 (86.9) 63 (82.9) 101 (87.8) 58 (89.2) 44 (88.0)
Degenerative 15 (4.9) 7 (9.2) 4 (3.5) 2 (3.1) 2 (4.0)
Mixed 20 (6.5) 5 (6.6) 9 (7.8) 5 (7.7) 1 (2.0)
Other 5 (1.6) 1 (1.3) 1 (0.9) 0 (0.0) 3 (6.0)
EuroSCORE II, % 6.1 (3.7-10.4) 5.8 (3.1-13.2) 5.9 (3.6-10.8) 6.1 (4.2-9.6) 6.2 (3.8-9.3) 0.94
STS mortality, % 4.0 (2.6-6.6) 4.5 (2.4-7.4) 3.9 (2.6-6.5) 4.3 (2.7-66) 4.0 (2.4-6.0) 0.89
Hemoglobin, g/dL 10.3  2.4 10.5  2.5 10.3  2.4 10.0  2.5 10.5  2.4 0.63
eGFR, mL/min/1.73 m2 47.1  19.7 47.7  18.4 45.4  20.0 48.4  20.1 48.6  20.4 0.68
NT-proBNP, pg/mL 2,760 (1,502-5,702) 3,037 (1,550-6,454) 3,089 (1,649-5,780) 2,550 (1,373-4,891) 2,107 (1,108-4,313) 0.31
AST, U/L 28.0 (22.0-35.0) 28.2 (22.5-36.9) 28.4 (22.2-35.6) 26.4 (20.7-33.0) 27.0 (23.0-37.4) 0.79
ALT, U/L 19.8 (14.9-26.0) 19.8 (16.0-28.6) 21.0 (14.0-28.0) 17.4 (14.0-23.2) 19.0 (14.3-24.8) 0.27
GGT, U/L 94.0 (54.0-167.5) 87.0 (47.7-128.0) 96.3 (56.0-173.8) 95.7 (52.5-155.5) 110.0 (74.0-230.5) 0.11
Beta-blockers 264 (86.3) 72 (93.5) 97 (84.3) 57 (89.1) 38 (76.0) 0.03
Anti-RAAS 210 (70.2) 52 (67.5) 72 (65.5) 51 (81.0) 35 (71.4) 0.17
Aldosterone antagonists 135 (44.1) 27 (35.1) 56 (48.7) 27 (42.2) 25 (50.0) 0.23

Values are mean  SD, median (IQR), or n (%).

ALT ¼ alanine aminotransferase; AST ¼ aspartate aminotransferase; BMI ¼ body mass index; COPD ¼ chronic obstructive pulmonary disease; eGFR ¼ estimated glomerular filtration rate;
ICD ¼ intracardiac defibrillator; MI ¼ myocardial infarction; NT-proBNP ¼ N-terminal pro–B-type natriuretic peptide; NYHA ¼ New York Heart Association; PM ¼ pacemaker; RAAS ¼ renin-
angiotensin-aldosterone system; RV ¼ right ventricle; STS ¼ Society of Thoracic Surgeons; TEER ¼ transcatheter edge-to-edge repair; TR ¼ tricuspid regurgitation; TVG ¼ tricuspid valve
gradient.

was in atrial fibrillation), and the average was re-
ported. TR severity was graded into 4 grades (ie, mild
[1þ], moderate [2þ], severe [3þ], and massive/
torrential [4þ]) using a combination
quantitative and quantitative
described by the American Society of Echocardiogra-
phy guidelines and the European Association of
Echocardiography guidelines. 17-19 Procedural success
was defined as the patient alive at the end of the
procedure with the device successfully implanted and
the delivery system retrieved with a residual TR #2þ.
CLINICAL OUTCOMES. The primary endpoint was
mortality from any cause or HF hospitalization. The
secondary endpoints were overall mortality, HF hos-
pitalization, and functional class. Follow-up data
were collected at discharge, at 30 days, and then ac-
cording to the time frame elapsed from the index
procedure to data lock for the present analysis.
of semi- Follow-up clinical events and echocardiographic data
assessment as were collected by each local investigator and pro-
vided to the international data coordinating center.
STATISTICAL ANALYSIS. Categoric variables were
reported as numbers and corresponding proportions
and compared with the chi-square test with conti-
nuity correction or the Fisher exact test as appro-
priate. Continuous variables were described as mean
 SD or median (IQR) and compared with 1-way
analysis of variance (parametric test) or the Kruskal-
Wallis test (nonparametric test) according to their
distribution. The cumulative survival and freedom
710 Coisne et al JACC: CARDIOVASCULAR INTERVENTIONS VOL. 16, NO. 6, 2023

Impact of Tricuspid Valve Gradient After TEER MARCH 27, 2023:706–717

T A B L E 2 Baseline Echocardiographic Characteristics According to Post-TEER TVG Quartiles

Overall Quartile 1 Quartile 2 Quartile 3 Quartile 4

(N ¼ 308) (n ¼ 77) (n ¼ 115) (n ¼ 65) (n ¼ 51) P Value

LVEF, % (n ¼ 305) 49.8  13.9 48.0  15.5 49.1  13.0 51.0  14.2 52.6  12.4 0.24
LVEDD, mm (n ¼ 297) 50.9  9.2 52.1  9.5 50.4  8.8 51.0  9.5 50.3  9.3 0.62
Left atrial volume, mL (n ¼ 258) 102.5  46.4 102.7  41.8 98.2  44.6 111.9  49.9 99.4  52.8 0.34
TVG, mm Hg (n ¼ 273) 1.2  0.6 1.1  0.4 1.2  0.5 1.3  0.7 1.7  0.9 <0.001
TR severity (n ¼ 308) 0.02
2/4 11 (3.6) 6 (7.9) 4 (3.5) 1 (1.5) 0 (0.0)
3/4 142 (46.3) 38 (50.0) 58 (50.4) 30 (46.2) 16 (31.4)
4/4 154 (50.2) 32 (42.1) 53 (46.1) 34 (52.3) 35 (68.6)
Concomitant MR $3þ (n ¼ 308) 126 (40.9) 33 (42.9) 54 (47.0) 22 (33.8) 17 (33.3) 0.22
TR jet location (n ¼ 308) 0.36
Central 187 (60.7) 45 (58.4) 76 (66.1) 40 (61.5) 26 (51.0)
Anteroseptal 45 (14.6) 13 (16.9) 16 (13.9) 11 (16.9) 5 (9.8)
Anteroposterior 6 (1.9) 3 (3.9) 1 (0.9) 1 (1.5) 1 (2.0)
Posteroseptal 17 (5.5) 3 (3.9) 8 (7.0) 2 (3.1) 4 (7.8)
Unknown 53 (17.2) 13 (16.9) 14 (12.2) 11 (16.9) 15 (29.4)
TR vena contracta, cm (n ¼ 266) 0.99  0.38 0.93  0.36 0.94  0.31 1.05  0.40 1.14  0.46 0.01
TR RV, mL (n ¼ 149) 48.5  27.1 44.5  23.9 48.0  22.1 48.7  35.1 58.6  32.3 0.34
TR EROA, cm2 (n ¼ 247) 0.64  0.52 0.56 þ 0.49 0.69  0.55 0.66  0.57 0.66  0.44 0.50
TV annulus diameter, mm (n ¼ 262) 46.8  7.5 48.2  7.3 46.6  7.8 46.5  6.6 45.3  8.2 0.27
Tricuspid coaptation depth, mm (n ¼ 194) 9.0  3.7 9.5  4.2 8.7  3.3 9.0  3.3 9.1  4.3 0.64
Tricuspid tenting area, cm2 (n ¼ 192) 2.2  1.3 2.5  1.8 2.1  1.1 2.1  1.1 2.1  1.2 0.35
RVEDD, mm (n ¼ 135) 40.3  12.7 38.9  11.1 41.5  14.2 40.8  10.1 39.1  15.0 0.77
Right atrial volume, mL (n ¼ 194) 101.6  53.9 95.3  50.0 101.4  52.5 114.0  66.9 94.1  38.5 0.35
TAPSE, mm (n ¼ 277) 16.7  5.1 18.0  6.5 16.9  4.6 15.7  4.5 16.8  4.3 0.10
SPAP, mm Hg (n ¼ 144) 41  15.8 40.6  15.3 41.6  15.7 40.6  15.9 40.7  17.5 0.97

Values are mean  SD or n (%).

EROA ¼ effective regurgitant orifice area; LVEDD ¼ left ventricular end diastolic diameter; LVEF ¼ left ventricular ejection fraction; MR ¼ mitral regurgitation; RV ¼ regurgitant volume;
RVEDD ¼ right ventricular end diastolic diameter; SPAP ¼ systolic pulmonary artery pressure; TAPSE ¼ tricuspid plane systolic excursion; other abbreviations as in Table 1.

from unplanned HF hospitalization were estimated RESULTS

using the Kaplan-Meier method and compared using
the log-rank test. HRs and 95% CIs were determined
using Cox proportional hazards regression. Multivar-
iable Cox regression analyses were performed with
adjustment for age, sex, atrial fibrillation, diabetes
mellitus, chronic obstructive pulmonary disease, and
discharge TR severity. The relationship between the
discharge TVG and the risk of interested outcomes
was further explored with Cox proportional hazards
regression models by entering the TVG measurement
as a restricted cubic spline with 5 knots located at the
5th, 25th, 50th, 75th, and 95th percentiles. Receiver-
operating characteristic (ROC) curve analysis was
used to assess the predictive ability of TVG on the
primary composite endpoint. Multivariable linear
regression analysis was performed to identify pre-
dictors of an increased discharge TVG. A 2-sided P
value <0.05 was considered statistically significant.
Statistics were performed using R, version 4.1.3 (The
R Foundation for Statistical Computing).
COMPARISON OF TVG QUARTILES. A total of 308
patients who underwent tricuspid TEER from August
2015 to March 2022 were included in the present
study. The overall mean TVG at discharge echocar-
diography was 2.3  1.5 mm Hg. Patients were
divided into the following quartiles of mean TVG
distribution: 0.0 to 1.1 mm Hg (Q1, n ¼ 77), 1.2 to
2.0 mm Hg (Q2, n ¼ 115), 2.1 to 3.0 mm Hg (Q3,
n ¼ 65), and 3.1 to 16.2 mm Hg (Q4, n ¼ 51). The mean
TVGs among groups were 0.9  0.3 mm Hg (Q1), 1.8 
0.3 mm Hg (Q2), 2.8  0.3 mm Hg (Q3), and 4.7 
2.0 mm Hg (Q4) (Central Illustration). Fifteen patients
(4.9%) showed a mean TVG $5 mm Hg. Baseline
characteristics in the different quartiles are depicted
in Table 1. Patients in Q4 had a higher prevalence of
previous left-sided valve intervention (P < 0.01) and
a lower use of beta-blockers (P ¼ 0.03). There were no
differences in all remaining baseline characteristics
across Q1 to Q4.
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 16, NO. 6, 2023 Coisne et al 711
MARCH 27, 2023:706–717 Impact of Tricuspid Valve Gradient After TEER

T A B L E 3 Procedural Characteristics and Postprocedural Outcomes According to Post-TEER TVG Quartiles

Overall Quartile 1 Quartile 2 Quartile 3 Quartile 4

(N ¼ 308) (n ¼ 77) (n ¼ 115) (n ¼ 65) (n ¼ 51) P Value

Procedure
Duration of procedure, min 122.9  52.1 114.8  45.3 114.9  39.9 140.4 70.8 135.5  57.3 0.01
Concomitant mitral or aortic intervention 102 (43.2) 22 (36.7) 41 (47.1) 22 (42.3) 17 (45.9) 0.63
Number of tricuspid clips implanted 0.32
1 16 (5.3) 7 (9.2) 4 (3.5) 3 (4.7) 2 (4.2)
2 70 (23.1) 18 (23.7) 30 (26.1) 11 (17.2) 11 (22.9)
3 144 (47.5) 37 (48.7) 57 (49.6) 30 (46.9) 20 (41.7)
4 65 (21.5) 12 (15.8) 24 (20.9) 17 (26.6) 12 (25.0)
$5 8 (2.6) 2 (2.6) 0 (0.0) 3 (4.7) 3 (6.2)
Number of tricuspid clips implanted 1.9  0.9 1.8  0.9 1.9  0.8 2.1  0.9 2.1  1.0 0.11
Postprocedural echocardiography
TR severity 0.14
0/4 6 (2.0) 1 (1.3) 3 (2.6) 2 (3.1) 0 (0.0)
1/4 136 (44.6) 42 (55.3) 50 (43.9) 26 (40.0) 18 (36.0)
2/4 114 (37.4) 25 (32.9) 49 (43.0) 22 (33.8) 18 (36.0)
3/4 39 (12.8) 6 (7.9) 9 (7.9) 13 (20.0) 11 (22.0)
4/4 10 (3.3) 2 (2.6) 3 (2.6) 2 (3.1) 3 (6.0)
Delta TR severity (post- vs pre-TR severity) 0.53
0 22 (7.2) 3 (4.0) 7 (6.1) 7 (10.8) 5 (10.0)
1 92 (30.3) 27 (36.0) 32 (28.1) 17 (26.2) 16 (32.0)
2 130 (42.8) 28 (37.3) 54 (47.4) 30 (46.2) 18 (36.0)
3 59 (19.4) 17 (22.7) 21 (18.4) 10 (15.4) 11 (22.0)
4 1 (0.3) 0 (0.0) 0 (0.0) 1 (1.5) 0 (0.0)
Tricuspid valve gradient, mm Hg 2.3  1.5 0.9  0.3 1.8  0.3 2.8  0.3 4.7  2.0 <0.01
Delta TVG, mm Hg 1.10  1.14 0.06  0.19 0.74  0.47 1.52  0.66 2.93  1.13 <0.01
TV annulus diameter, mm 44.6  7.6 46.2  7.0 43.9  7.2 43.6  8.3 45.1  8.4 0.34
LVEF, % 49.8  14.1 48.6  15.8 50.0  13.4 49.8  14.1 51.2  13.0 0.78
TAPSE, mm 16.0  4.5 17.0  4.8 15.9  4.4 15.6  4.6 15.4  3.9 0.26
SPAP, mm Hg 38.7  12.7 38.0  13.4 38.9  12.2 38.1  12.9 39.8  12.8 0.87
Postprocedural outcomes
AKI 30 (12.2) 8 (12.9) 13 (13.7) 7 (13.7) 2 (5.4) 0.59
New-onset atrial fibrillation 4 (1.6) 0 (0.0) 2 (2.0) 0 (0.0) 2 (5.4) 0.15
Length of stay, d 4.0 (2.0-6.0) 3.0 (2.0-5.0) 4.0 (2.0-6.0) 4.0 (3.0-5.0) 3.0 (2.0-7.0) 0.55
Conversion to surgery 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) NA
In-hospital all-cause mortality 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) NA

Values are mean  SD, median (IQR), or n (%).

AKI ¼ acute kidney injury; S-TDI ¼ S-tissue Doppler imaging; other abbreviations as in Tables 1 and 2.

Echocardiographic variables are shown in Table 2.
No differences were observed in terms of left ven-
tricular ejection fraction, left and right ventricular
end-diastolic diameters, left and right atrial volumes,
and systolic pulmonary artery pressure. Preoperative
TR grading and severity, as assessed by vena con-
tracta width, were higher in Q4 (P ¼ 0.01 and P ¼ 0.02,
respectively). Most patients (n ¼ 217, 71.6%) were
implanted with $3 clips with no differences among Q1
to Q4 (P ¼ 0.32) (Table 3), and all groups obtained a
similar benefit in terms of postprocedural
(P ¼ 0.32). Patients in Q4 had higher frequencies of
residual TR $3þ (Q1 ¼ 10.5%, Q2 ¼ 10.5%, Q3 ¼ 23.1%,
and Q4 ¼ 28.0%; P < 0.01) and a lower procedural
success rate (Q1 ¼ 89.5%, Q2 ¼ 86.8%, Q3 ¼ 76.9%,
and Q4 ¼ 72%; P ¼ 0.02). The overall length of stay
was 4.0 days (IQR: 2.0-6.0 days) with no in-hospital
mortality. Analyses stratifying the population per
post-TEER TVG median are provided in Supplemental
Tables 1 to 3 and showed similar results compared
with the quartile distribution. Finally, there were no
differences between the mean TVG post-TEER and
those at the last TTE follow-up (n ¼ 90, 2.16  1.28 vs
2.28  1.22, respectively; P ¼ 0.26).
TR
ASSOCIATION BETWEEN TVG QUARTILES AND
CLINICAL OUTCOMES. The median (Q1-Q3) duration
of follow-up was 174 days (IQR: 43-364 days).
712 Coisne et al
Impact of Tricuspid Valve Gradient After TEER
F I G U R E 1 Kaplan-Meier Curves of Clinical Outcomes According to Post-TEER TVG Quartiles
There was no difference in 1-year freedom from (left) death or (right) heart failure (HF) hospitalization among the 4 quartiles of post– transcatheter edge-to-edge
repair (TEER) tricuspid valve gradient (TVG) distribution.
T A B L E 4 Multivariable Analysis on 1-Year Outcomes After Tricuspid TEER
Adjusted Hazard Adjusted
Ratio (95% CI) P Value
All-cause mortality or HF hospitalization
Q4, reference Q1-Q3 0.97 (0.47-1.97) 0.93
Age, per 1-year increase 1.02 (0.98-1.05) 0.32
Male 1.18 (0.69-2.02) 0.54
Atrial fibrillation 0.72 (0.43-1.23) 0.24
Diabetes mellitus 1.75 (1.02-3.02) 0.04
Chronic obstructive pulmonary disease 0.94 (0.52-1.71) 0.84
Post-TEER TR >2þ 2.20 (1.17-4.11) 0.01
All-cause mortality
Q4, reference Q1-Q3 0.80 (0.27-2.31) 0.67
Age, per 1-year increase 1.04 (0.99-1.10) 0.09
Male 0.99 (0.47-2.11) 0.99
Atrial fibrillation 0.31 (0.14-0.71) 0.005
Diabetes mellitus 2.11 (1.02-4.40) 0.04
Chronic obstructive pulmonary disease 0.56 (0.21-1.49) 0.24
Post-TEER TR >2þ 2.60 (1.07-6.32) 0.04
HF hospitalization
Q4, reference Q1-Q3 1.13 (0.53-2.42) 0.75
Age, per 1-year increase 1.01 (0.97-1.05) 0.56
Male 1.24 (0.67-2.26) 0.49
Atrial fibrillation 0.84 (0.46-1.51 0.55
Diabetes mellitus 2.31 (1.27-4.22) 0.006
Chronic obstructive pulmonary disease 1.03 (0.53-1.98) 0.94
Post-TEER TR >2þ 2.70 (1.38-5.28) 0.004
HF ¼ heart failure; Q ¼ quartile; other abbreviations as in Table 1.
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 16, NO. 6, 2023
MARCH 27, 2023:706–717
Outcomes at 30 days are presented in Supplemental
Table 4. An increasing prevalence of residual TR
>2þ was observed from Q1 to Q4 (Q1 ¼ 10.8%,
Q2 ¼ 20.4%, Q3 ¼ 25.0%, and Q4 ¼ 45.7%; P < 0.01). At
1 year, the composite endpoint of all-cause mortality
and HF hospitalization occurred in 63 (20.4%) pa-
tients, all-cause mortality in 34 (11.0%) patients, and
HF hospitalization in 48 (15.6%) patients. Kaplan-
Meier analyses at 1 year showed no differences
among TVG quartiles for the freedom from the com-
posite endpoint of all-cause mortality or HF hospi-
talization (Q1 ¼ 65%, Q2 ¼ 70%, Q3 ¼ 60%, and
Q4 ¼ 66%; P ¼ 0.60; Central Illustration), all-cause
mortality (Q1 ¼ 73%, Q2 ¼ 84%, Q3 ¼ 82%, and
Q4 ¼ 80%; P ¼ 0.58), and HF hospitalization
(Q1 ¼ 72%, Q2 ¼ 79%, Q3 ¼ 64%, and Q4 ¼ 69%;
P ¼ 0.44; Figure 1). After multivariable adjustment for
age, sex, atrial fibrillation, diabetes mellitus, chronic
obstructive pulmonary disease, and post-TEER re-
sidual TR severity, TVG in Q4 compared with Q1 to Q3
was not independently associated with 1-year rates of
the primary combined endpoint (HR: 0.97; 95% CI:
0.47-1.97; P ¼ 0.93) (Table 4, Supplemental Table 5).
Similar findings were observed for its components,
including all-cause mortality (P ¼ 0.67) and HF
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 16, NO. 6, 2023 Coisne et al 713
MARCH 27, 2023:706–717 Impact of Tricuspid Valve Gradient After TEER

F I G U R E 2 Changes in NYHA Functional Class From Baseline to Last Follow-Up by Post–Transcatheter Edge-to-Edge Repair TVG Quartiles

No significant differences in New York Heart Association (NYHA) functional class III/IV were observed between tricuspid valve gradient (TVG)
quartile (Q) 4 and TVG Q1 to Q3 at each time point. *Comparison for NYHA functional class III/IV.

hospitalization (P ¼ 0.75). Finally, there was no dif-
ference between patients in Q4 and patients in Q1 to
Q3 regarding New York Heart Association functional
class III to IV before TEER (P ¼ 0.78), at 30 days
(P ¼ 0.84), and at the last follow-up (P ¼ 0.63)
(Figure 2, Supplemental Figure 1).
After multivariable adjustment, the baseline TVG
(P ¼ 0.0001) and the number of implanted clips
(P ¼ 0.004) were independently associated with a
higher TVG post-TEER (Supplemental Table 6).
No association was observed for baseline or residual
TR.

IMPACT AND PREDICTORS OF INCREASED TVG AS A
CONTINUOUS VARIABLE. We used restricted cubic
spline regression analyses to assess whether there
was a nonlinear relationship between TVG measured
on discharge echocardiography as a continuous vari-
able and clinical outcomes. No nonlinear associations
were found for every investigated endpoint (all
P > 0.05) (Figure 3). In addition, a ROC curve for
prediction of the composite endpoint at 1 year was
performed. The ROC curve did not show any predic-
tive capacity of the post-TEER TVG for all-cause
mortality or HF hospitalization (ROC AUC: 0.52;
95% CI: 0.44-0.60; P ¼ 0.52) (Supplemental Figure 2).
SUBGROUP ANALYSIS. To further explore the asso-
ciation between post-TEER TVG and residual TR with
clinical outcomes, patients were classified into 4
groups based on discharge TVG quartiles and residual
TR severity as follows: group 1, TVG Q1 to Q3 and
TR #2þ (n ¼ 220); group 2, TVG Q4 and TR #2þ (n ¼ 36);
group 3, TVG Q1 to Q3 and TR >2þ (n ¼ 35); and group 4,
TVG Q4 and TR >2þ (n ¼ 14). There was no difference in
outcomes between groups 1 and 2 (HR: 0.71; 95% CI:
0.28-1.80; P ¼ 0.47), groups 3 and 4 (HR: 1.34; 95% CI:
0.47-3.88; P ¼ 0.58), and groups 1 and 3 (HR: 1.58;
95% CI: 0.77-3.27; P ¼ 0.21). There was a trend for an
increased risk of death or HF hospitalization between
714 Coisne et al JACC: CARDIOVASCULAR INTERVENTIONS VOL. 16, NO. 6, 2023

Impact of Tricuspid Valve Gradient After TEER MARCH 27, 2023:706–717

groups 2 and 4 (HR: 3.15; 95% CI: 0.91-10.94; P ¼ 0.07).

F I G U R E 3 Spline Regression Analyses of Post–Transcatheter Edge-to-Edge Repair
TVG and Clinical Outcomes
Finally, there were no significant differences in
freedom from all-cause mortality or HF hospitalization
stratifying the population according to the cutoff
of 3 mm Hg 20 (TVG $3 mm Hg ¼ 66%, TVG
<3 mm Hg ¼ 66%; P ¼ 0.97) or the TVG median
(TVG $2 mm Hg ¼ 62%, TVG <2 mm Hg ¼ 68%; P ¼ 0.39)
(Supplemental Figure 3).

DISCUSSION

To the best of our knowledge, this study represents

the largest analysis of postprocedural TVG and its
impact on outcomes after tricuspid TEER. Exploring
the TVG measured at discharge in 308 patients after
tricuspid TEER within the TriValve registry, we found
that: 1) higher TVGs were associated with higher re-
sidual TR and lower procedural success; 2) patients
with a higher TVG after tricuspid TEER had similar
rates of all-cause mortality, HF hospitalization, and
comparable functional capacity after the 1-year
follow-up compared with those with a lower TVG;
and 3) the baseline TVG and the number of implanted
clips are independently associated with the post-
TEER TVG.
There are conflicting data regarding the impact of
an increased mitral valve gradient (MVG) after mitral
TEER.13 Exploring 268 patients who underwent
mitral TEER, Neuss et al 12 showed that an increased
mitral valve pressure gradient assessed invasively or
with echocardiography at implantation was associ-
ated with significantly poorer long-term outcomes.
Conversely, Yoon et al14 showed that an increased
mean mitral valve gradient was not independently
associated with adverse events after TEER in 419
patients with primary MR. A substudy from the
COAPT (Cardiovascular Outcomes Assessment of the
MitraClip Percutaneous Therapy for Heart Failure
Patients With Functional Mitral Regurgitation) trial
highlighted that higher mitral valve gradients on
discharge did not adversely affect clinical outcomes
after MitraClip (Abbott) implantation.11 Interestingly,
the clinical impact of MVG after TEER appears to
differ depending on the MR mechanism (ie, primary
vs secondary). Indeed, 2 studies from Patzelt et al21
and Koell et al22 found that an elevated mitral valve
pressure gradient was predictive of long-term out-
comes after TEER in patients with degenerative MR
but not in functional MR. In order to extend these
results to TR, it is important to point out that the vast
majority (90%-95%) of TR cases have a functional
There were no significant correlations between tricuspid valve gradient (TVG) as a
mechanism.
continuous variable and clinical outcomes as assessed by spline regression analysis.
HF ¼ heart failure; TV ¼ tricuspid valve.
Because of differences in anatomical and func-
tional characteristics, the results observed on the
JACC: CARDIOVASCULAR INTERVENTIONS VOL. 16, NO. 6, 2023
MARCH 27, 2023:706–717
mitral valve may not be valid for the tricuspid valve
(TV). Indeed, the TV, which is composed of 3 or more
leaflets,23 is larger than the mitral valve, 24-26 espe-
cially in atrial fibrillation patients, 27 who represent
most of the patients with significant secondary TR.
The TV is also subject to a lower pressure; therefore,
the inflow velocities and gradients across the TV are
lower than across the mitral valve.
Data regarding the impact of the TVG after surgical
TV repair or replacement are scarce. Normal bio-
prosthetic mean gradients across a wide variety of
biological prostheses range between <6 to 9 mm Hg.28
For TV repair, transvalvular gradients may be lower.
In 71 patients who underwent prophylactic tricuspid
annuloplasty with a flexible ring, Shim et al29 found
that the TVG was low after surgery (1.65
0.74 mm Hg) and remained stable over a 5-year
follow-up. In 419 patients who underwent concomi-
tant tricuspid annuloplasty for moderate TR and/or
tricuspid annular dilatation during mitral valve
repair, Chikwe et al 30 found that the mean post-
operative TVG was 2 mm Hg. To date, there is no clear
evidence on the impact of the postoperative TVG on
TV biological prosthesis dysfunction or clinical out-
comes after TV surgery.28
Although there is no generally accepted grading of
tricuspid stenosis severity, a mean echocardiographic
TVG $5 mm Hg defines significant native valvular
tricuspid stenosis in international guidelines.31,32 The
definition of significant bioprosthetic TV stenosis in
the VIVID (Valve-in-Valve International Database)
registry was a mean gradient $10 mm Hg empirically
derived by the baseline hemodynamics of that patient
population.33 In the first study on tricuspid TEER, an
“acceptable” gradient after clipping was arbitrarily
defined as a TVG #3 mm Hg. 20 Based on that arbitrary
expert definition, Orban et al 15 showed that patients
with a TVG >3 mm Hg at discharge had the same
midterm outcomes as patients with a TVG #3 mm Hg
in a single-center study of 145 patients. Our study
confirms this finding, showing no adverse outcomes
associated with a TVG >3 mm Hg (mean gradient in
Q4 of 4.7  2.0 mm Hg).
Like the mitral valve, residual TV regurgitation is a
major determinant of outcomes after tricuspid
9,34
TEER. Therefore, minimizing residual TR is the
primary goal of tricuspid TEER. In many cases, this
objective can only be achieved by implanting several
clips with the risk of generating an iatrogenic
tricuspid stenosis. In the present study, we demon-
strated that after adjustment for confounding risk
factors, a higher postprocedural TVG was not inde-
pendently associated with the occurrence of the pri-
mary and secondary endpoints at the 1-year follow-up
Coisne et al 715
Impact of Tricuspid Valve Gradient After TEER
after tricuspid TEER. Future studies are needed to
assess whether any difference may emerge with
higher TV gradients not observed in this registry or at
longer-term follow-up.
STUDY LIMITATIONS. The most relevant limitations
of this study are inherent in its nonrandomized,
observational design; therefore, our results have to be
considered as hypotheses generating. Because of the
retrospective nature of this study, some parameters
of tricuspid valve stenosis were not routinely
assessed (ie, the tricuspid valve orifice area, peak
velocity, or Doppler velocity index). Even if the
evaluation of tricuspid stenosis usually requires the
integration of several echocardiographic and clinical
parameters (eg, heart rate), the assessment of TVG
 solely based on Doppler analysis is reproducible and
easy to acquire in daily practice. We acknowledge the
relatively small sample size of the population, espe-
cially with high TVG, the short duration of follow-up,
and the lack of echocardiographic core laboratory and
independent clinical events adjudication. Although
our conclusions must be explored in randomized tri-
als, these data contain the most comprehensive in-
formation on elevated TVGs and prognosis in patients
undergoing tricuspid TEER so far. Finally, we
acknowledge that the TVG at discharge may be
different from the TVG in the operating room because
of changes in loading conditions and heart rate under
general anesthesia.
CONCLUSIONS
In this retrospective analysis of the TriValve registry,
an increased TVG at discharge was not significantly
associated with adverse outcomes after tricuspid
TEER. These findings apply to the explored TVG
range and up to the 1-year follow-up. Further in-
vestigations on higher gradients and longer follow-up
are needed to better guide the intraprocedural
decision-making process.
FUNDING SUPPORT AND AUTHOR DISCLOSURES
Dr Coisne has served as a consultant for Abbott; and has received
speaker fees from Abbott and GE Healthcare. Dr Scotti has served as a
consultant for NeoChord Inc; and has received consulting fees from
NeoChord Inc. Dr Taramasso has served as a consultant for Abbott
Vascular, Boston Scientific, 4Tech, and CoreMedic; and has received
speaker honoraria from Edwards Lifesciences. Dr Ludwig has
received travel compensation from Edwards Lifesciences. Dr Rodés-
Cabau has received institutional research grants from Edwards Life-
sciences. Dr Lurz has received speaker fees from Abbott. Dr Hausleiter
has received speaker honoraria from Abbott Vascular and Edwards
Lifesciences. Dr Kodali has served on the scientific advisory board for
Microinterventional Devices, Dura Biotech, Thubrikar Aortic Valve,
and Supira; has served as a consultant for Meril Lifesciences,
716 Coisne et al JACC: CARDIOVASCULAR INTERVENTIONS VOL. 16, NO. 6, 2023

Impact of Tricuspid Valve Gradient After TEER MARCH 27, 2023:706–717

Admedus, Medtronic, and Boston Scientific; has served on the
steering committee for Edwards Lifesciences and Abbott Vascular;
has received honoraria from Meril Lifesciences, Admedus, Abbott
Vascular, and Dura Biotech; and owns equity in Dura Biotech, Thu-
brikar Aortic Valve, Supira, and MID. Dr Alessandrini has received
consulting fees from Abbott and Edwards LifeSciences. Dr Brochet
has received speaker fees from Abbott Vascular. Dr Denti has served
as a consultant for Abbott Vascular, 4Tech, Neovasc, and InnovHeart;
and has received honoraria from Abbott and Edwards Lifesciences. Dr
Estévez- Loureiro has received speaker fees from Abbott, Boston, and
Edwards Lifesciences. Dr Ho has served as a consultant for NeoChord
Inc; and has received consulting fees from NeoChord Inc. Dr Praz has
received travel expenses from Edwards Lifesciences, Abbott Vascular,
and Polares Medical. Dr Sievert has received study honoraria, travel
expenses, and consulting fees from 4Tech Cardio, Abbott, Ablative
Solutions, Ancora Heart, Bavaria Medizin Technologie, Bioventrix,
Boston Scientific, Carag, Cardiac Dimensions, Celonova, Comed BV,
Contego, CVRx, Edwards Lifesciences, Endologix, Hemoteq, Lifetech,
Maquet Getinge Group, Medtronic, Mitralign, Nuomao Medtech,
Occlutech, PFM Medical, ReCor, Renal Guard, Rox Medical, Terumo,
Vascular Dynamics, and Vivasure Medical. Dr Tang has served as a
consultant, physician advisory board member, and faculty trainer for
Abbott Structural Heart; has served as a consultant for Medtronic and
NeoChord; and has served as a physician advisory board member for
JenaValve. Dr Andreas has served as a proctor/consultant for and has
received speaker fees from Abbott, Edwards LifeSciences, Boston,
Zoll and Medtronic; and has received institutional grants from
Edwards Lifesciences, Abbott, Medtronic, and LSI Solutions. Dr
Gavazzoni has served as a consultant for Abbott Vascular. Dr Braun
has received speaker honoraria and travel support from Abbott
Vascular. Dr Lubos has received grant support and lecture fees from
Abbott; and has received lecture fees from Edwards Lifesciences. Dr
Kalbacher has received lecture fees from Abbott and Edwards Life-
sciences. Dr Connelly has received honoraria from Abbott. Dr Schofer
has served as a consultant for Edwards Lifesciences. Dr Windecker
reports research, travel, or educational grants to the institution from
Abbott, Abiomed, Amgen, AstraZeneca, Bayer, Biotronik, Boehringer
Ingelheim, Boston Scientific, Bristol Myers Squibb, Cardinal Health,
CardioValve, Corflow Therapeutics, CSL Behring, Daiichi Sankyo,
Edwards Lifesciences, Guerbet, InfraRedx, Janssen-Cilag, Johnson &
Johnson, Medicure, Medtronic, Merck Sharp & Dohme, Miracor
Medical, Novartis, Novo Nordisk, Organon, OrPha Suisse, Pfizer,
Polares, Regeneron, Aventis, Servier, Sinomed, Terumo, Vifor, and V-
Wave. Dr Windecker serves as an unpaid advisory board member
and/or unpaid member of the steering/executive group of trials fun-
ded by Abbott, Abiomed, Amgen, AstraZeneca, Bayer, Boston Scien-
tific, Biotronik, Bristol Myers Squibb, Edwards Lifesciences, Janssen,
MedAlliance, Medtronic, Novartis, Polares, Recardio, Sinomed, Ter-
umo, V-Wave, and Xeltis, but has not received personal payments by
pharmaceutical companies or device manufacturers. He is also a
member of the steering/executive committee group of several
investigator-initiated trials that receive funding by industry without
impact on his personal remuneration. Dr Maisano has served as a
consultant for and received consulting fees and honoraria from
Abbott Vascular, Edwards Lifesciences, Cardiovalve, SwissVortex,
Perifect, Xeltis, Transseptal Solutions, Magenta, Valtech, and Med-
tronic; has reported being a cofounder of 4Tech; has received
research grant support from Abbott, Medtronic, Edwards Life-
sciences, Biotronik, Boston Scientific, NVT, and Terumo; has received
royalties and owns intellectual property rights from Edwards Life-
sciences (FMR surgical annuloplasty); and has reported being a
shareholder in Cardiovalve, Swiss Vortex, Magenta, Transseptal So-
lutions, Occlufit, 4Tech, and Perifect. Dr Leon has received institu-
tional clinical research grants from Abbott, Boston Scientific, Edwards
Lifesciences, and Medtronic. Dr Hahn has served as a consultant for
Abbott Vascular, Abbott Structural, NaviGate, Philips Healthcare,
Medtronic, Edwards Lifesciences, and GE Healthcare; has been the
Chief Scientific Officer for the Echocardiography Core Laboratory at
the Cardiovascular Research Foundation for multiple industry-
supported trials, for which she receives no direct industry compen-
sation; has received speaker fees from Boston Scientific and Baylis
Medical; and has received nonfinancial support from 3mensio. Dr
Latib has served on the advisory board for Medtronic, Abbott Vascular
Boston Scientific, Edwards Lifesciences, Shifamed, NeoChord Inc, V-
dyne, and Philips. All other authors have reported that they have no
relationships relevant to the contents of this paper to disclose.
ADDRESS FOR CORRESPONDENCE: Dr Azeem Latib,
Section Head, Interventional Cardiology, Montefiore
Medical Center/Albert Einstein College of Medicine,
1825 Eastchester Road, Bronx, New York 10461, USA.
E-mail: alatib@gmail.com.
PERSPECTIVES
WHAT IS KNOWN? The balance between reaching
an optimal TR reduction and risking an iatrogenic
tricuspid stenosis is a central issue in any tricuspid
TEER procedure.
WHAT IS NEW? Among patients with significant TR,
higher TVGs on discharge echocardiography were not
significantly associated with adverse outcomes up to 1
year after tricuspid TEER.
WHAT IS NEXT? Further investigations on higher
gradients and longer follow-up are needed to better
guide the intraprocedural decision-making process.

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J Am Coll Cardiol Intv. 2021;14(20):2260–2270.
KEY WORDS transcatheter edge-to-edge
repair, transcatheter tricuspid valve
intervention, tricuspid regurgitation,
tricuspid valve gradient
A PP END IX For supplemental tables and
figures, please see the online version of this
paper.