Multimodal Evaluation of Right Ventricular Remodeling and Exercise Response After Tricuspid Transcatheter Edge-to-Edge Repair

Background: Once regarded as a neglected valvular disorder, Tricuspid Regurgitation (TR) is now recognized as a progressive condition with considerable clinical burden. Tricuspid Transcatheter Edge-to-Edge Repair (T-TEER) offers a minimally invasive treatment option for high-risk patients, yet evidence on functional recovery, especially under stress conditions, remains limited. Objectives: To explore the extent of functional recovery under physical exertion and the occurrence of early right ventricular reverse remodeling (eRVRR) following T-TEER in patients with severe TR. To identify associations between clinical improvement and baseline risk factors. Methods: In this single-center, retrospective-prospective case-control study, 82 patients (mean age 77.2 ± 7.8 years; 78% female) with advanced TR were enrolled. Thirty-two patients underwent T-TEER (TriClip® in 96.9%, PASCAL in the remainder), while 50 matched controls received standard care. All participants underwent a comprehensive multimodal assessment, including transthoracic and transesophageal echocardiography, 6-minute walk test (6MWT), and semi-supine cycle ergometer stress echocardiography. Right heart catheterization was selectively performed in patients with a procedural indication. Mean follow-up was 11.7 ± 7.5 months, with repeated stress testing to assess functional recovery and right heart performance. Results: At follow-up, T-TEER cases showed significant functional gains: 6MWT distance increased to 380.8 ± 70.6 m vs. 25.5 ± 6.6 m in controls (p < 0.001), and peak workload improved significantly (p < 0.001). NYHA class and TR severity significantly improved in cases but worsened in controls (both p < 0.001). Evidence of eRVRR was observed in the case group, with significant changes in TAPSE, TAPSE/PAPs ratio, and pulmonary pressures (all p < 0.001). Improvements in both exercise capacity and right ventricular parameters were more pronounced in patients without major cardiovascular risk factors (as diabetes, smoking, dyslipidemia; all p < 0.05). Conclusions: T-TEER led to significant functional improvement under exertion and signs of early right ventricular reverse remodeling. These preliminary findings suggest that, beyond symptom relief, T-TEER may contribute to restoring right heart function in patients with advanced tricuspid regurgitation (TR) and right-sided heart failure. Notably, baseline risk factors such as diabetes, smoking, CKD, and prior cardiovascular events appear to modulate the extent of benefit.