Innovations in transcatheter tricuspid valve interventions: what has failed, what has worked, what is coming

Innovation in transcatheter tricuspid valve intervention has advanced by learning from what did not work and expanding what does. Early attempts, often adapted from the mitral space, exposed practical constraints and safety tradeoffs that underscored how distinct the tricuspid valve is in anatomy, imaging, and physiology. Transcatheter edge-to-edge repair has shown improvement in symptoms, health status, and functional capacity with a favorable safety profile, when anatomy is suitable. Orthotopic transcatheter tricuspid valve replacement (TTVR) reliably abolishes regurgitation across complex anatomies, while ongoing iteration targets pacemaker rates, delivery system size, and right ventricular function. Heterotopic bicaval systems relieve venous congestion for patients unsuited to orthotopic solutions. These modalities are complementary in practice: repair is preferred when leaflet anatomy permits, TTVR is definitive when repair is unlikely to succeed, and caval approaches expand options for advanced disease. Looking ahead, the field is converging on devices and workflows that are simpler, smaller, and more anatomy-agnostic, with renewed interest in physiology-guided designs across new annuloplasty, replacement, spacer, and caval platforms. Longer-term readouts from randomized programs will test durability, right-sided remodeling, and hospitalization effects. Finally, responsible dissemination that emphasizes imaging expertise and structured pathways will be essential as access grows. Taken together, the field has moved from exploratory ideas to proven solutions and a credible near-term pipeline, positioning transcatheter therapy to deliver durable, patient-centered benefit for tricuspid regurgitation