Mortality rates by therapeutic approaches for isolated severe tricuspid regurgitation: a systematic review
Authors: Suc G , Mesnier J , Cailliau A , Delhomme C , Himbert D , Ducrocq G , Iung B , Urena M 
Published: October 2024

Abstract

Background
Managing isolated severe tricuspid regurgitation (TR) poses significant challenges, with questions recently arising about the efficacy of surgical and percutaneous therapies compared to conservative approaches in improving survival.

Purpose
This systematic review aims to evaluate the mortality associated with various treatment modalities for isolated severe TR.

Methods
A comprehensive search of medical databases was conducted. Studies reporting mortality of isolated TR at 1-year follow-up, with TR severity classified as moderate-to-severe or worse, were included. Exclusion criteria were TR associated with left-heart disease and combined procedures (treating other valves). The primary endpoint was all-cause mortality at 1-year, with secondary outcomes including in-hospital, 2 and 5 years mortality. Patients with isolated severe TR were categorized by management type: medical, percutaneous, or surgical. Percutaneous treatment included all types of transcatheter therapy (repair or replacement), and surgical interventions encompassed both repair and replacement procedures.

Results
Twenty-nine studies met the inclusion criteria. Mean age was 72 years among the 5970 patients managed medically, 77 years among the 1205 patients treated percutaneously, and 60 years among the 1754 patients managed surgically. In medically managed patients, 1-year, 2-year, and 5-year mortality rates were 23.6%, 32.5%, and 45.9% respectively. Among percutaneously managed patients, there was an in-hospital mortality of 2.5% and a 1-year mortality rate of 16.9%, which increased to 27.9% at 2 years. Surgically managed patients experienced an in-hospital mortality of 8.6% (p&lt;0.001 compared to percutaneous treatment), with 1-year, 2-year, and 5-year mortality rates of 19.8%, 21.7% and 33.5%, respectively. Compared to medical management, both transcatheter therapy and surgical management demonstrated significantly lower mortality rates at 1 year (p&lt;0.001 vs. percutaneous treatment; p=0.02 vs. surgery), with no significant differences between surgical and percutaneous treatment (p=0.16). At 2-year follow-up, patients undergoing surgical management exhibited significantly lower mortality compared to the other groups (p&lt;0.001 vs. medical treatment; p=0.02 vs. percutaneous treatment), while mortality rates between medical and percutaneous treatment was not different (p=0.11).

Conclusion
The findings underscore the significant long-term mortality associated with isolated severe TR. While selection bias should be considered, invasive management, through either percutaneous or surgical interventions, demonstrates superior 1-year survival rates compared to medical management. Surgical therapy appears to offer the lowest long-term mortality in selected, operable patients, potentially due to their younger age. Further research is warranted to refine patient selection criteria and optimize therapeutic strategies to improve outcomes in the management of isolated TR.