Fixing a leaky heart valve helps people in their 80s live longer

A leaky valve on the right side of the heart has long been treated as a sign of advanced illness. Doctors could ease the fluid build-up with water tablets, but repairing the valve itself, especially in frail older people, wasn't shown to help anyone live longer. A German trial presented at ESC Congress 2026 has changed that.

In TRIC-I-HF, older people with severe tricuspid regurgitation who had the valve repaired through a vein in the leg, on top of their usual medicines, were far less likely to die or be admitted to hospital with heart failure over three years than those who had medicines alone. It is the first randomised trial to show that this type of procedure improves survival and hospital admissions as well as symptoms.

The trial was presented by Professor Jörg Hausleiter of Ludwig-Maximilians-University (LMU) Munich in the Hot Line 7 session on 30 August 2026, which ran from 11:00 to 12:15 Munich time (the same in Madrid), and published simultaneously in the New England Journal of Medicine.

What tricuspid regurgitation is

The heart has four valves that keep blood flowing in one direction. The tricuspid valve sits between the two chambers on the right side, the right atrium and the right ventricle. When it doesn't close properly, blood leaks backwards with each heartbeat. This is called tricuspid regurgitation.

Mild leaks are common and harmless. Severe leaks are a different matter. Blood backs up into the veins, causing swollen legs, a swollen abdomen, breathlessness and tiredness. Over time, the congestion can damage the kidneys and liver. Doctors call these effects cardiorenal and cardiohepatic syndromes.

Severe tricuspid regurgitation is most common in older people, often alongside atrial fibrillation or other heart conditions. For years it was nicknamed the "forgotten valve", because surgeons rarely operated on it alone. Open-heart surgery on the tricuspid valve carries high risks in elderly patients with failing hearts, and outcomes have been poor.

Repair through a vein

Transcatheter repair avoids open surgery. A doctor passes a thin tube (catheter) through a vein in the groin up to the heart. The most common approach, transcatheter edge-to-edge repair (T-TEER), uses small clips to pin the valve leaflets together so they close more tightly. Two devices dominate: Edwards Lifesciences' Pascal system and Abbott's TriClip.

Earlier randomised trials, Tri.Fr in France and the TRILUMINATE trial in the US, showed that T-TEER improved quality of life. Neither showed fewer deaths or heart failure admissions. That left an open question over whether the procedure changed the course of the disease or simply made people feel better.

The TRIC-I-HF trial

TRIC-I-HF (NCT04634266) was run between March 2022 and June 2025 at 29 high-volume heart valve centres across Germany. It was led by Hausleiter and Professor Thomas Stocker of LMU Munich and funded by the German Centre for Cardiovascular Research (DZHK), with support from LMU's university hospital and an unrestricted research grant from Edwards Lifesciences.

The researchers deliberately chose patients at high risk of heart failure events. To take part, people needed symptomatic severe tricuspid regurgitation plus at least one of the following: a heart failure hospital admission in the previous year, cardiorenal syndrome, or cardiohepatic syndrome.

That produced a sick and elderly group. Of the 360 people enrolled:

• The average age was 80.3, and 56.4% were women
• 75% had moderate to severe heart failure symptoms (NYHA class III or IV)
• 55% had been admitted to hospital with heart failure in the previous year
• 81.7% had cardiorenal syndrome and 46.2% had cardiohepatic syndrome
• The leak was graded severe in 50.8%, massive in 34.2% and torrential in 10.3%

People were randomly assigned in a 2:1 ratio to transcatheter repair plus medicines (237 people) or medicines alone (123 people). In the repair group, 98.3% had T-TEER, 1.3% had a ring-tightening procedure (annuloplasty) and 0.4% had the valve replaced. Pascal was used in 65.6% and TriClip in 33%. Most people (62%) needed two clips.

People in the medicines-only group could cross over to repair if they were admitted to hospital with severe heart failure needing intravenous water tablets. By the end, 48 had done so.

Two main goals

The trial had two primary endpoints, tested in sequence.

The first used a method called a win ratio. Every patient in the repair group was compared with every patient in the medicines group, pair by pair. Death was compared first, then heart failure admissions, then improvement in quality of life at one year. The win ratio is the number of pairs where the repair patient did better divided by the number where the medicines patient did better.

If the first goal was met, the second was the more traditional measure: the proportion of people alive and free of heart failure admissions after three years.

What the trial found

Both goals were met by a wide margin.

The win ratio at one year was 2.42 (95% confidence interval 1.76 to 3.33, p<0.001). In other words, repair patients came out ahead in about two and a half times as many comparisons as they came out behind.

Over three years, 52.4% of people in the repair group were alive and had avoided a heart failure admission, compared with 21.0% in the medicines group. That is a 60% lower relative risk (hazard ratio 0.40, 95% confidence interval 0.29 to 0.55, p<0.001).

The benefit came from both deaths and admissions. By three years, deaths from any cause were 38% lower with repair (hazard ratio 0.62, 95% confidence interval 0.40 to 0.96). Heart failure admissions were 65% lower (hazard ratio 0.35). Analyses that accounted for the fact that people who die can no longer be admitted to hospital gave the same answer.

Hausleiter said the number needed to treat was four: repairing the valve in four patients prevented one death or heart failure admission at one year.

On safety, 14 people (5.9%) in the repair group had a major adverse event within 30 days of the procedure.

"Early and pronounced separation of the event curves in these patients with advanced heart failure [shows] the immediate benefit of tricuspid valve repair when added to optimised medical therapy, establishing the intervention as an effective disease-modifying therapy," Hausleiter said in the ESC press release.

How experts reacted

The trial's discussant, Dr Rebecca Hahn of NewYork-Presbyterian and Columbia University Irving Medical Center, called it "just an incredible result," as reported by TCTMD. She pointed to three design choices: enrolling high-risk patients, requiring experienced centres, and letting operators choose which approved device to use. Together, she said, this showed that "the heart team discussion was integral to this trial result."

Dr Mohamad Alkhouli of the Mayo Clinic, who wasn't involved, told TCTMD that it "feels like a COAPT-like moment for the field." COAPT was the 2018 trial that showed a similar clip procedure for the mitral valve, on the left side of the heart, reduced deaths and admissions in heart failure. Alkhouli suggested the repair may help by easing congestion, which in turn lets heart failure medicines work better.

Session chair Professor Nicolas Van Mieghem said he hoped the trial would "stimulate future guideline committees in formulating updated recommendations for the treatment of tricuspid regurgitation with transcatheter interventions."

Questions that remain

The trial was not blinded. Patients knew whether they'd had a procedure, which can colour how they rate their quality of life, part of the first endpoint. Deaths and hospital admissions are harder outcomes, and they pointed the same way.

Other caveats:

• Crossover. Almost 40% of the medicines group (48 of 123) crossed over to repair after a heart failure admission. Hahn raised the question of how this affected the admission results and whether some patients can safely stay on medicines alone.
• Selection. The trial enrolled a high-risk group at experienced German centres. John Mandrola, a cardiologist and commentator, noted that the leaks in TRILUMINATE were more severe at baseline than in TRIC-I-HF, raising questions about how patient selection explains the different results. Whether the benefit holds at less experienced centres, or in people at lower risk, is unknown.
• Small control group. The 2:1 design left 123 people on medicines alone. The three-year estimates carry wide confidence intervals.
• Too late for some. Hahn also asked whether some patients had disease too advanced to benefit, which future analyses may help answer.

What it could mean for patients

For older people with severe tricuspid regurgitation and repeated heart failure admissions, TRIC-I-HF provides the first strong evidence that valve repair through a vein can help them live longer and stay out of hospital. The DZHK said the procedures could be performed safely even in older people with several health problems.

Current guidelines give transcatheter tricuspid repair a cautious recommendation, mainly for symptom relief. Guideline committees will now weigh whether to strengthen that. In the meantime, anyone with a leaky tricuspid valve and worsening heart failure symptoms may want to ask their cardiologist whether they should be assessed at a specialist valve centre.

This article explains published research and isn't medical advice. Talk to your own doctor or specialist team before changing any treatment.