Peripheral edema in patients with severe tricuspid regurgitation (TR) who have undergone transcatheter tricuspid valve replacement (TTVR) is indicative of a “highly adverse prognosis,” according to a new retrospective analysis. The findings were published Monday online in JACC: Cardiovascular Interventions. TR has emerged as a cause of substantial morbidity and mortality, yet treatment paradigms lack robust risk stratification, claimed the researchers from Ruhr University Bochum, Germany, led by Hazem Omran, MD. One potential factor — peripheral edema — may signal a particularly high-risk, adverse clinical and hemodynamical phenotype, they noted, adding that, while it is a hallmark of right heart failure, it is not universal in TR. “Importantly, waiting for edema to appear before intervention may miss the window for optimal patient benefit,” they wrote. The current study set out to investigate peripheral edema as a prognostic marker in TR via a single-center study on 254 consecutive patients with severe symptomatic TR who underwent TTVR between 2018 and 2023. Patents were followed for a mean time of 12 months. Peripheral edema was clinically adjudicated at baseline and was present in 154 of the total study cohort (61%). These patients tended to be older, (mean age 79.7 ± 6.9 vs 77.7 ± 7.9 years; P = 0.038), with a higher prevalence of atrial fibrillation (92% vs 80%; P = 0.004), diabetes and chronic kidney disease. They also demonstrated shorter 6-minute walk distance (a mean 215m ± 97 vs 255m ± 100; P = 0.04), increased end-organ impairment (lower hemoglobin, albumin and estimated glomerular filtration rate; P < 0.05 for all) and higher median TRISCORE2 results (7 [interquartile range: 6-8] vs 5 [IQR: 4-6]; P = 0.001). No significant differences in cardiac medication were found between the groups. “Of interest, use and doses of loop diuretic agents were not different between those with and those without edema,”the researchers noted. “Likewise, serum N-terminal pro–brain natriuretic peptide levels were not significantly different between the groups.” The researchers found that the edema group had elevated pulmonary artery (PA) pressures (P = 0.001) and right atrial pressures (P = 0.001). Procedural success was lower for edema patients (80% vs 91%; P = 0.007), which the researchers said was driven by fewer achievements of ≥2-grade TR reduction (77.3% vs 91%; P = 0.005). Post-procedural (30 day) success was also lower for edema sufferers (75% vs 91%; P = 0.002), regardless of device type used. “Nonetheless, both groups improved in NYHA functional class post-TTVR,” the researchers noted. Heart failure hospitalization (HFH) data was available for 162 of the 254 patients (63.8%) with an overall incidence of HFH of 13.3% at a median 3.2 month follow-up. Edema patients showed a trend towards higher HFH risk (16.7% vs 8.6%; log-rank P = 0.09). At a mean 12-month follow-up, all-cause mortality was significantly higher for those with edema. On multivariable Cox regression, baseline edema remained an independent predictor of 1-year mortality (hazard ratio [HR]: 9.75; 95% confidence interval [CI]: 1.29-73.8; P = 0.027). The researchers went on to highlight other significant mortality predictors in the study, namely right ventricular pulmonary artery (RV-PA) coupling from right heart catheterization, intraprocedural succuss and baseline mitral regurgitation of at least moderate severity. “Notably, patients without edema derived the greatest benefits: higher acute procedural success and markedly improved survival,” they wrote. They concluded that the study supports previous studies suggesting that edema is independently prognostic in TTVR patients and pushed for routine congestion phenotyping. “Importantly, conventional echocardiographic metrics failed to detect these high-risk features; only clinical and invasive data captured the advanced state,” they noted. “Peripheral edema defines a TR phenotype with advanced congestion, worse RV-PA coupling, and higher mortality risk despite similar TR severity. These patients derive less procedural benefit from TTVR, underscoring the need for earlier referral and intervention, ideally before the onset of overt volume overload. “[…]Treatment strategies should be refocused on timely referral and pre-emptive management of severe TR—before the development of edema—using both invasive hemodynamic status and clinical assessment for risk stratification.” Source: Omran H, Al Masalmeh M, Kirchner J, et al. More Than a Symptom: Peripheral Edema as a Prognostic Marker in Tricuspid Regurgitation. JACC: Cardiovasc Interv 2026; DOI: j.jcin.2025.11.039. Image Credit: iushakovsky – stock.adobe.com