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Vera Fortmeier, Mark Lachmann, Matthias Unterhuber, Lukas Stolz, Mohammad Kassar, Laurin Ochs, Muhammed Gerçek, Anne R. Schöber, Thomas J. Stocker, Hazem Omran, Maria Isabel Körber, Amelie Hesse, Kai Friedrichs, Shinsuke Yuasa, Tanja Rudolph, Michael Joner, Roman Pfister, Stephan Baldus, Karl‐Ludwig Laugwitz, Fabien Praz, Stephan Windecker, Jörg Hausleiter, Philipp Lurz, Volker Rudolph

• \(\bf BACKGROUND:\) Tricuspid regurgitation (TR) frequently develops in patients with long-standing pulmonary hypertension, and both pathologies are associated with increased morbidity and mortality. This study aimed to improve prognostic assessment in patients with severe TR undergoing transcatheter tricuspid valve intervention (TTVI) by relating the extent of TR to pulmonary artery pressures. \(\textbf {METHODS AND RESULTS:}\) In this multicenter study, we included 533 patients undergoing TTVI for moderate-to-severe or severe TR. The proportionality framework was based on the ratio of tricuspid valve effective regurgitant orifice area to mean pulmonary artery pressure. An optimal threshold for tricuspid valve effective regurgitant orifice area/mean pulmonary artery pressure ratio was derived on 353 patients with regard to 2-year all-cause mortality and externally validated on 180 patients. Patients with a tricuspid valve effective regurgitant orifice area/mean pulmonary artery pressure ratio \(\leq\)1.25\(mm^{2}\)/mmHg (defining proportionate TR) featured significantly lower 2-year survival rates after TTVI than patients with disproportionate TR (56.6% versus 69.6%; \(\it P\)=0.005). In contrast with patients with disproportionate TR (n=398), patients with proportionate TR (n=135) showed more pronounced mPAP levels (37.9\(\pm\)9.06mmHg versus 27.9\(\pm\)8.17mmHg; \(\it {P}<2.2×10^{−16}\)) and more severely impaired right ventricular function (tricuspid annular plane systolic excursion: 16.0\(\pm\)4.11 versus 17.0\(\pm\)4.64mm; \(\it P\)=0.012). Moreover, tricuspid valve effective regurgitant orifice area was smaller in patients with proportionate TR when compared with disproportionate TR (0.350\(\pm\)0.105\(cm^{2}\) versus 0.770\(\pm\)0.432\(cm^{2}\); \(\it {P}<2.2×10^{−16}\)). Importantly, proportionate TR remained a significant predictor for 2-year mortality after adjusting for demographic and clinical variables (hazard ratio, 1.7; \(\it P\)=0.006). \(\bf CONCLUSIONS:\) The proposed proportionality framework promises to improve future risk stratification and clinical decisionmaking by identifying patients who benefit the most from TTVI (disproportionate TR). As a next step, randomized controlled studies with a conservative treatment arm are needed to quantify the net benefit of TTVI in patients with proportionate TR.