Impact of tricuspid valve morphology on outcomes after transcatheter edge-to-edge repair: insights from the euroTR registry

Background

Advanced imaging in tricuspid regurgitation (TR) has revealed substantial variability in tricuspid valve morphology beyond the classical tri-leaflet configuration, with many patients exhibiting additional or non-uniform leaflet segments. Such anatomical complexity may increase procedural difficulty during tricuspid transcatheter edge-to-edge repair (T-TEER). The Hahn et al. classification provides a standardized framework for morphological assessment of the tricuspid valve (TV).

Aims

To evaluate the impact of tricuspid valve morphology on procedural efficacy and clinical outcomes following T-TEER.

Methods

This analysis is based on the multicentre, real-world EuroTR registry, including patients with relevant tricuspid regurgitation undergoing T-TEER between 2016 and 2025 at 20 European centres. Tricuspid valve morphology was systematically classified according to Hahn et al., and patients were stratified accordingly. Procedural efficacy was assessed by TR reduction at discharge using a cumulative link mixed model. Clinical outcomes were evaluated by Kaplan–Meier analysis, with a composite endpoint of all-cause mortality or heart failure hospitalization.

Results

Among 726 patients with sufficient imaging quality for morphological stratification (median age 80 years [IQR 76–84]; 55% female), the distribution of TV morphologies closely mirrored that reported by Hahn et al., with Type I (52.9%) and Type IIIb (25.3%) being most prevalent. Baseline characteristics were well balanced across morphology groups. Baseline TR severity differed between morphology types, with Type II morphology associated with more severe TR, reflected by a larger effective regurgitant orifice area (p=0.012).

Type I morphology was associated with the most pronounced TR reduction and superior procedural efficacy compared with Type IIIb (p=0.02; OR 1.86 [95% CI 1.10–3.13]) and with all other morphology types pooled due to smaller sample sizes (p=0.001; OR 2.63 [95% CI 1.53–4.53]) (Figure 1A). Despite more severe baseline regurgitation severity, TR reduction in Type II morphology was comparable to that observed in Type I (p=0.121; OR 1.78 [95% CI 0.89–3.57]). Kaplan–Meier analysis of the composite endpoint of all-cause mortality or heart failure hospitalization at three years revealed no significant differences between morphology types (Figure 1B).

Conclusion

In this large real-world registry, the distribution of TV morphologies closely reflected that previously reported by Hahn et al. While Type I anatomy was statistically most amenable to T-TEER and achieved the greatest TR reduction, long-term clinical outcomes were comparable across morphology types.Figure 1