A 2026 expert consensus document from the American College of Cardiology (ACC), American Heart Association (AHA), American Society of Echocardiography, Heart Rhythm Society, and Society of Thoracic Surgeons provides detailed recommendations for establishing and maintaining programs for transcatheter tricuspid valve interventions.
The document emphasizes systems of care needed to support these procedures, including multidisciplinary team–based evaluation, institutional infrastructure, operator experience, and longitudinal outcomes tracking as transcatheter tricuspid valve repair and replacement expand following US Food and Drug Administration approvals.
Multidisciplinary Team Central to Care
The consensus identifies the multidisciplinary team as a foundational component of tricuspid valve intervention programs. Minimum team membership includes a general or valve cardiologist, heart failure specialist, interventional echocardiographer, multimodality imaging specialists, interventional cardiologist, cardiac valve surgeon, electrophysiologist or cardiac implantable electronic device specialist, cardiac anesthesiologist, and program support staff.
The team is responsible for confirming tricuspid regurgitation severity, ensuring guideline-directed medical and device therapy has been optimized, assessing procedural feasibility and risk, and providing consensus treatment recommendations through shared decision-making.
Multimodality imaging—including transthoracic and transesophageal echocardiography, computed tomography, and cardiac magnetic resonance—is described as essential for diagnosis and procedural planning.
Institutional and Operator Requirements
Institutions offering tricuspid valve interventions should maintain an active cardiac surgical program with at least two surgeons, established interventional cardiology services, comprehensive cardiovascular imaging capabilities, and access to electrophysiology expertise.
The document specifies minimum thresholds for program initiation, including:
- at least 50 open-heart surgeries annually
- at least 20 tricuspid valve surgeries over 2 years
- either at least 50 transcatheter aortic valve implantation procedures and 20 edge-to-edge repairs annually, or equivalent 2-year volumes
Operator requirements include at least 50 structural heart procedures, including 20 edge-to-edge repairs, along with board certification or eligibility and device-specific training.
Procedural Standards
For transcatheter tricuspid valve edge-to-edge repair, procedures should be performed by at least two physicians working as cooperators, including an interventional echocardiographer and either an interventional cardiologist or cardiac surgeon.
For transcatheter tricuspid valve replacement, three physician operators should initially participate: an interventional echocardiographer, an interventional cardiologist, and a cardiac surgeon. Institutions may transition to a reduced operator team only after demonstrating procedural safety, defined as a 30-day major complication rate below 20% after at least 25 cases or 3 years of experience.
Registry Participation and Outcomes Tracking
The document states that centers incorporating transcatheter tricuspid valve interventions should participate in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry to support postmarket surveillance, long-term outcomes tracking, and comparative effectiveness research.
Standardized performance metrics include, among others, in-hospital and 30-day mortality, major bleeding and vascular complications, residual tricuspid regurgitation, heart failure rehospitalization, patient-reported outcomes such as Kansas City Cardiomyopathy Questionnaire scores, procedural conversion, and tricuspid stenosis measures.
The Centers for Medicare & Medicaid Services provides coverage under a coverage with evidence development pathway, which requires collection of at least 24 months of outcomes data.
Program Maintenance and Volume Thresholds
To maintain a transcatheter tricuspid valve edge-to-edge repair program, centers should perform at least 20 tricuspid valve interventions annually, including 10 transcatheter procedures, or equivalent 2-year volumes.
For transcatheter tricuspid valve replacement programs, thresholds include at least 20 tricuspid interventions annually, including 10 transcatheter procedures and 5 replacements.
Higher procedural volume has been associated with improved outcomes, with analyses suggesting survival after edge-to-edge repair improves with increasing case experience.
Evidence Base and Clinical Context
The recommendations are based on randomized trials, registry data, and expert consensus, reflecting an evolving evidence base.
In pivotal trials, transcatheter tricuspid valve interventions improved quality-of-life measures compared with medical therapy alone, without demonstrated differences in mortality at 1 year. Evidence regarding longer-term outcomes, including heart failure hospitalization, continues to evolve.
In the TRILUMINATE trial, transcatheter edge-to-edge repair plus optimal medical therapy improved a composite outcome vs medical therapy alone, driven primarily by quality-of-life gains. Kansas City Cardiomyopathy Questionnaire scores increased by 12.3 points vs 0.6 points at 1 year, while mortality and heart failure hospitalization rates were similar at that time point.
In the TRISCEND II trial, transcatheter valve replacement plus medical therapy was superior to medical therapy alone, driven by improvements in quality of life and New York Heart Association class, with no difference in 1-year mortality or hospitalization.
“Rigorous data collection and comparative analysis, inclusive of functional status and quality-of-life indicators, will be essential to validate the appropriateness of the continued growth in procedural volumes,” wrote Patrick T. O’Gara, MD, of Brigham and Women’s Hospital, and colleagues.
Disclosures
Relevant author and peer reviewer relationships are reported in the document appendixes, with comprehensive disclosures available in the supplemental materials.
Source: JACC
