Tricuspid Transcatheter Edge-to-Edge Repair (TEER)
Dr Dawkins performs this procedure at Cleveland Clinic London and at the John Radcliffe Hospital in Oxford, where he is Clinical Lead for Structural Intervention.
Transcatheter tricuspid edge-to-edge repair (TEER) is a technique used to treat a leaking tricuspid valve (tricuspid regurgitation) without open-heart surgery.
Dr Dawkins uses both the Pascal and TriClip devices for these procedures.
How does tricuspid edge-to-edge repair work?
A repair device (Pascal or TriClip) is delivered on its delivery system (a long steerable tube) into one of the veins in the leg. It is steered into the right side of the heart using x-rays and ultrasound. The tricuspid valve leaflets are grasped over the leak and the device is closed. If this has reduced the leak sufficiently, then the clip can be released. If not, the clip can be moved or re-orientated as needed. Most patients need more than one clip, depending on the size and location of the leak. The aim is to reduce the leak substantially.
Who is tricuspid edge-to-edge repair recommended for?
Tricuspid TEER is currently recommended for patients with symptomatic (usually breathlessness, fatigue, leg swelling or abdominal swelling) severe tricuspid regurgitation who are at increased risk for open-heart surgery. There are many reasons why someone may be at increased risk for open-heart surgery, for example previous heart surgery, other significant medical problems (e.g. liver, kidney or lung disease), atrial fibrillation, the presence of pacemaker or defibrillator leads, or frailty. The right ventricle and the rest of the heart need to be functioning well enough for the procedure to be likely to help, which is one of the things we assess carefully in the work-up.
What is the process for deciding to treat someone with this technique?
Generally you would be referred by your GP or cardiologist. You would then be assessed in clinic by Dr Dawkins, which may include additional investigations, typically a transthoracic echocardiogram, a transoesophageal echocardiogram (TOE), and a cardiac CT scan. Once we have all the necessary information, we will discuss you at one of our regular structural valve meetings. These are attended by interventional cardiologists, cardiac surgeons, imaging experts and anaesthetists. If the consensus is that this would be a good treatment for you, and you would like to go ahead, we will offer you a procedure date.
What can I expect from the procedure?
The procedure can usually be carried out within one to two weeks of referral. Most patients are admitted on the morning of the procedure. The procedure is carried out under general anaesthetic (you will be asleep) with continuous transoesophageal echocardiogram (TOE) guidance. The procedure usually takes about an hour. Afterwards, you will wake up on our recovery ward and will then be transferred back to the ward. Some patients go home the same day, but most stay in hospital for one night, and some need an extra day for monitoring. Dr Dawkins will see you in clinic a month or so after the procedure, but can be contacted in the interim if you have any queries or problems.
What are the benefits and risks?
A successful procedure reduces the severity of tricuspid regurgitation, which usually translates into improved breathlessness, less leg and abdominal swelling, and better exercise tolerance over the following weeks and months. Like any procedure there are risks, including bleeding from the access site, valve injury, the need for further intervention, and rarely stroke or significant heart-related complications. We will discuss your individual risk profile in detail at your consultation, both verbally and in writing, and again before the procedure.
What experience does Dr Dawkins have in tricuspid edge-to-edge repair?
Dr Dawkins is one of the highest-volume operators in the UK for transcatheter mitral and tricuspid intervention. He performed the first tricuspid edge-to-edge repair in the UK with the Pascal device, the first with the TriClip device, and the first combined mitral and tricuspid repair with Pascal. He teaches the technique internationally, and clinicians visit Oxford from around the world to learn Pascal and TriClip procedures with him.
He also offers transcatheter tricuspid valve replacement with EVOQUE and caval valve implantation with TricValve, making him one of very few clinicians in the UK able to offer the full range of transcatheter tricuspid options. This means the treatment can be matched to your valve anatomy.
How to choose: TEER, EVOQUE or TricValveWhich tricuspid treatment suits which valve
Three transcatheter options
There are three ways to treat a leaking tricuspid valve without open-heart surgery: tricuspid edge-to-edge repair (TEER), EVOQUE valve replacement and TricValve. All three are carried out through a vein at the top of the leg, under general anaesthetic, and usually take about an hour.
Which one is right for you depends mainly on the anatomy of your tricuspid valve. This is assessed in detail with a transoesophageal echocardiogram and a CT scan, and every patient is discussed at a structural valve meeting before a procedure is offered.
Tricuspid edge-to-edge repair (Pascal or TriClip)
- How it works: clips hold the leaflets of your own valve together to reduce the leak.
- When it is used: it is usually the first choice when the leaflets can be brought together.
- Advantages: it is a very safe procedure, it keeps your own valve, and it rarely affects the heart’s electrical wiring. Most patients go home the same day or after one night.
- Limitations: some leak usually remains. Repair is less likely to work well when the gap between the leaflets is too wide, the leaflets are too short or tethered, or a pacemaker wire through the valve gets in the way.
EVOQUE valve replacement
- How it works: a new valve is placed inside your own tricuspid valve.
- When it is used: when repair is unlikely to reduce the leak enough.
- Advantages: it usually removes the leak almost completely.
- Limitations: there is a higher chance of needing a pacemaker. Blood-thinning medication is needed afterwards, so this technology may not be suitable for patients who have difficulties with bleeding or cannot tolerate oral anticoagulation (blood-thinning tablets). Not every valve is the right size or shape for EVOQUE. Most patients go home after one night.
TricValve Caval Valve Implantation
- How it works: two valves are placed in the large veins that bring blood back to the heart, to stop blood being pushed backwards into the liver, abdomen and legs.
- When it is used: when neither repair nor replacement is suitable, most often because the tricuspid valve is too large.
- Advantages: it can relieve swelling and congestion in patients who have no other transcatheter option, and it rarely affects the heart’s electrical wiring.
- Limitations: it does not reduce the leak in the tricuspid valve itself. Blood-thinning medication is needed afterwards, so this technology may not be suitable for patients who have difficulties with bleeding or cannot tolerate oral anticoagulation (blood-thinning tablets). Most patients go home after one night.
Is a procedure always the right choice?
Not always. Everyone continues their heart medication, and for some patients medication alone remains the best treatment. European guidelines recommend that transcatheter treatment should be considered for patients with severe symptoms despite medication, as long as the right side of the heart is not severely weakened and there is no severe lung-related high blood pressure [1]. Dr Dawkins will go through all of the options with you, including not having a procedure.
References
- Praz F, et al. 2025 ESC/EACTS Guidelines for the management of valvular heart disease. European Heart Journal 2025;46:4635–4736. doi:10.1093/eurheartj/ehaf194
The evidence: key studiesPublished trial and registry results, with references
These summaries describe how tricuspid edge-to-edge repair was developed and tested, and the main published results. The figures are the results reported in those studies, not predictions for any individual patient. Where a study reports a P value, it is included. A P value shows how likely a difference of that size would be to arise by chance if the two treatments were really equal. A value below 0.05 is usually taken to mean the difference is unlikely to be due to chance ("statistically significant"). Dr Dawkins is happy to go through these results with you.
How was tricuspid edge-to-edge repair developed?
Edge-to-edge repair was first developed for the mitral valve, on the left side of the heart. Doctors then began to use the same clips on the tricuspid valve, initially on compassionate grounds, and dedicated studies followed.
- 2017 to 2018: the TRILUMINATE study. 85 patients at 21 centres in Europe and the United States were treated with TriClip. At one month, the leak was reduced by at least one grade in 86%. At six months, 86% had little or no breathlessness in everyday life, compared with 25% before treatment. There were no deaths or strokes during the procedure [1]. Dr Dawkins was involved in the study during his fellowship in the United States, and enrolled several patients.
- 9 April 2020: CE mark for TriClip. TriClip became the first edge-to-edge repair device approved in Europe for the tricuspid valve.
- 18 May 2020: CE mark for Pascal. Pascal was approved in Europe for the tricuspid valve the following month.
- 2023: the CLASP TR study. 65 patients in the United States were treated with Pascal. One year later, the leak was moderate or less in 86% of those who had a scan, compared with 3% before treatment, and 92% had little or no breathlessness in everyday life, compared with 4% before [2]. A European study of 74 patients treated with Pascal found similar results at one month [3].
- 21 April 2021: first in the UK. Dr Dawkins performed the first tricuspid edge-to-edge repair in the UK with Pascal, and on 25 May 2021 the first with TriClip.
- 2 April 2024: FDA approval for TriClip. The US Food and Drug Administration (FDA) approved TriClip.
Does it work better than medication alone?
Three randomised trials have compared edge-to-edge repair plus medication with medication alone. All three measured how patients felt using a standard questionnaire, the Kansas City Cardiomyopathy Questionnaire (KCCQ), scored from 0 to 100, where a higher score means fewer symptoms and a better quality of life.
- TRILUMINATE Pivotal (2023): 350 patients, treated with TriClip. After one year, patients who had the repair did better overall (P=0.02), mainly because they felt better: their questionnaire score improved by 12.3 points, compared with 0.6 points on medication alone (P<0.001) [4]. In the full group of 572 patients followed for two years, those who had the repair were admitted to hospital with heart failure less often (0.19 compared with 0.26 admissions per patient per year, P=0.02). The proportion who had died by two years was similar: 17.9% after repair and 17.1% on medication alone. Many patients on medication alone had the repair after the first year, which makes later comparisons harder [5].
- Tri.Fr (2025): 300 patients in France and Belgium, treated with TriClip. After one year, 74.1% of patients who had the repair were better overall, judged on their breathlessness, their own assessment and major heart events, compared with 40.6% on medication alone (P<0.001). Their questionnaire score improved by 15.9 points, compared with 0.4 points (P<0.001) [6].
- TRIC-I-HF (2026): 360 patients at 29 centres in Germany, whose heart failure was more advanced, for example with a recent hospital admission or effects on the kidneys or liver. Most were treated with Pascal (66%) or TriClip (33%). This was the first randomised trial to show that tricuspid edge-to-edge repair improves hard outcomes, death and hospital admission with heart failure, rather than symptoms alone [7]:
- Death or admission with heart failure: one year after the procedure, 73.9% of patients who had the repair were alive and had not been admitted with heart failure, compared with 48.4% on medication alone. By three years, this was 52.4% compared with 21.0% (P<0.001), although fewer patients have so far been followed for that long.
- Admission with heart failure: within the first year, 19.4% of patients who had the repair were admitted, compared with 43.9% on medication alone, which was statistically significant.
- Death: within the first year, 13.1% of patients who had the repair died, compared with 16.3% on medication alone. This difference was not statistically significant on its own.
- Overall: combining death, admissions and quality of life, patients who had the repair did better overall (P<0.001).
In 2025, European guidelines recommended for the first time that transcatheter treatment of the tricuspid valve, by repair or replacement, should be considered for suitable patients with severe symptoms despite medication [8].
How well does it stop the leak?
Edge-to-edge repair reduces the leak substantially in most patients, although some leak usually remains.
- TRILUMINATE Pivotal: one month after the procedure, the leak was moderate or less in 87.0% of patients who had the repair, compared with 4.8% on medication alone (P<0.001) [4]. Two years after the procedure, it was moderate or less in 84% [5].
- Tri.Fr: one year after the procedure, the leak was still massive or torrential (the two most severe grades) in 6.8% of patients who had the repair, compared with 53.5% on medication alone [6].
The less leak that remains, the better patients tend to do. In a European registry of 2,545 patients, 76.4% of those left with a mild leak or less were alive two years later, compared with 71.5% of those with a moderate leak and 58.9% of those with a severe leak or worse (P<0.001) [9]. This kind of study shows an association, not cause and effect, but it is one reason the aim is always to reduce the leak as much as safely possible.
What are the main risks?
Tricuspid edge-to-edge repair is a very safe procedure. It also rarely affects the heart’s electrical wiring, so a pacemaker is seldom needed afterwards.
The most specific risk of the procedure is single leaflet device attachment (SLDA). This is when a clip stays attached to only one of the two leaflets it was meant to hold together. When this happens, the clip no longer reduces the leak at that point, and the leak may increase.
- In routine practice: in a European registry of 1,059 patients treated with Pascal, 1.3% died within 30 days, and SLDA occurred in 3.5% [10].
- In TRIC-I-HF: 5.9% of patients had a major complication within 30 days, and SLDA occurred in 1.7%. One patient died within 30 days, from a cause not related to the heart [7].
Is everyone suitable for edge-to-edge repair?
Not every tricuspid valve can be repaired. The choice depends mainly on the anatomy of the valve, which is assessed in detail with a transoesophageal echocardiogram and a CT scan. Repair works best when the leaflets can be brought together. When the gap between them is too wide, the leaflets are too short or tethered, or a pacemaker wire through the valve gets in the way, EVOQUE valve replacement or TricValve may be more suitable.
Are the results as good outside clinical trials?
A registry of 1,059 patients treated with Pascal at 16 European centres between 2019 and 2023 reported results from routine practice. Dr Dawkins was one of the investigators. These patients were generally more unwell than those in the trials. The clip was implanted successfully in 98%. One year later, the leak was moderate or less in 83%, and 66% of patients had little or no breathlessness in everyday life, compared with 17% before treatment [10].
References
- Nickenig G, et al. Transcatheter edge-to-edge repair for reduction of tricuspid regurgitation: 6-month outcomes of the TRILUMINATE single-arm study. The Lancet 2019;394:2002–2011. doi:10.1016/S0140-6736(19)32600-5
- Kodali SK, et al. 1-year outcomes of transcatheter tricuspid valve repair. Journal of the American College of Cardiology 2023;81:1766–1776. doi:10.1016/j.jacc.2023.02.049
- Baldus S, et al. Transcatheter valve repair of tricuspid regurgitation with the PASCAL system: TriCLASP study 30-day results. Catheterization and Cardiovascular Interventions 2022;100:1291–1299. doi:10.1002/ccd.30450
- Sorajja P, et al. Transcatheter repair for patients with tricuspid regurgitation. New England Journal of Medicine 2023;388:1833–1842. doi:10.1056/NEJMoa2300525
- Kar S, et al. Two-year outcomes of transcatheter edge-to-edge repair for severe tricuspid regurgitation: the TRILUMINATE Pivotal randomized controlled trial. Circulation 2025;151:1630–1638. doi:10.1161/CIRCULATIONAHA.125.074536
- Donal E, et al. Transcatheter edge-to-edge repair for severe isolated tricuspid regurgitation: the Tri.Fr randomized clinical trial. JAMA 2025;333:124–132. doi:10.1001/jama.2024.21189
- Hausleiter J, et al. Tricuspid-valve intervention in heart failure. New England Journal of Medicine 2026. doi:10.1056/NEJMoa2606934
- Praz F, et al. 2025 ESC/EACTS Guidelines for the management of valvular heart disease. European Heart Journal 2025;46:4635–4736. doi:10.1093/eurheartj/ehaf194
- Stolz L, et al. The less the better: mild vs moderate residual tricuspid regurgitation after T-TEER: insights from EuroTR. JACC: Cardiovascular Interventions 2026;19:1319–1321. doi:10.1016/j.jcin.2026.02.047
- Wild MG, et al. Transcatheter valve repair for tricuspid regurgitation: 1-year results from a large European real-world registry. Journal of the American College of Cardiology 2025;85:220–231. doi:10.1016/j.jacc.2024.10.068