Tricuspid TEER — Advanced Procedural Strategies-Dr. Sugiura Use of Multi-Clip Strategy slides

Dr. Sugiura Use of Multi-Clip Strategy slides

Pdf Summary

This presentation by Dr. Atsushi Sugiura of Nagoya Heart Center focuses on the use of a multi-clip strategy with the TriClip G4 XTW device to treat complex tricuspid regurgitation (TR). The key challenge addressed is determining where to place multiple clips and how many are needed based on patient-specific valve anatomy and TR characteristics.<br /><br />Key considerations include evaluating the optimal clip length and width, pinpointing coaptation defects and TR jet locations, measuring the coaptation gap width (e.g., 10mm), presence of cardiac implantable electronic device leads, and leaflet configuration. For large coaptation gaps, placing the first clip at the anterior-septal (AS) commissure near the anterior scallop is recommended, followed by additional clips to effectively reduce TR and limit complications such as single leaflet device attachment (SLDA).<br /><br />Operators must confirm sufficient leaflet insertion and TR reduction before releasing the first clip, while assessing residual TR and the risk of tricuspid stenosis. A crucial step is collaborative agreement between operators and imagers on valve anatomy orientation and clip placement to ensure precise multi-clip deployment.<br /><br />The "zipping clover" technique can be used to address central TR and jets at the posterior-septal (PS) commissure, facilitating further clipping and annulus reshaping, although large PS gaps may complicate grasping and increase risk of device-related tears.<br /><br />Minor adjustments in clip "clocking" (rotation) may be necessary to optimize leaflet capture and close residual coaptation gaps. For complex leaflet morphology, central leaflet grasping combined with independent leaflet optimization may be more practical than clipping additional scallops.<br /><br />In summary, careful anatomic assessment, strategic clip placement based on valve morphology and TR jet location, and close collaboration between proceduralists and imagers are essential to successful multi-clip TR repair. Fluoroscopy aids in maneuvering and positioning multiple clips during the procedure.

Keywords

multi-clip strategy

TriClip G4 XTW

tricuspid regurgitation

clip placement

coaptation gap

leaflet insertion

single leaflet device attachment

zipping clover technique

valve morphology

fluoroscopy guidance