Tricuspid TEER — Advanced Procedural Strategies-Tricuspid Transcatheter Edge-to-Edge Repair eBook

Tricuspid Transcatheter Edge-to-Edge Repair eBook

Pdf Summary

This comprehensive guide provides an in-depth overview of Transcatheter Tricuspid Edge-to-Edge Repair (T-TEER) using the TriClip system, covering the clinical assessment, imaging evaluation, procedural techniques, complications, and case examples for management of tricuspid regurgitation (TR).

<strong>Clinical and Imaging Evaluation:</strong>  
TR is prevalent, especially in older adults, often secondary to right atrial or right ventricular dilation and dysfunction. Symptoms are frequently nonspecific and appear late, underscoring the importance of early detection. The guide emphasizes the need for thorough preprocedural imaging, primarily via transthoracic and transesophageal echocardiography (TTE and TEE), with advanced modalities like three-dimensional (3D) echocardiography and intracardiac echocardiography (ICE) for anatomical evaluation. Important imaging parameters include grading TR severity using an expanded 5-grade scheme, leaflet anatomy, coaptation gaps, and right heart function.

<strong>TriClip Device and Procedural Techniques:</strong>  
The TriClip G4 system is purpose-built to address the anatomical challenges of the tricuspid valve, including multiple leaflets and complex geometry. The system includes a steerable guide catheter (SGC), a clip delivery system (CDS), and a handle allowing precise steering and clip deployment. Right atrial steering aims to attain optimal device trajectory avoiding structures such as the Eustachian valve or intracardiac device leads. Intraprocedural imaging with TEE (with 2D, 3D, and multiplanar reconstruction) and adjunctive 3D ICE guidance helps confirm clip position, trajectory, leaflet grasping, and residual regurgitation.

<strong>Management of Complex Scenarios:</strong>  
Special strategies are highlighted for patients with cardiac implantable electronic devices (CIEDs), including evaluation of lead-related TR, risk of lead interference, and possible lead extraction. Various clip deployment strategies such as “zipping” and “clover” techniques are described to address complex valve anatomies and residual regurgitation, supported by multiplanar imaging.

<strong>Complications and Mitigation:</strong>  
The guide addresses potential complications including chordal entanglement, single leaflet device attachment (SLDA), clip embolization, iatrogenic tricuspid stenosis, vascular injury, and conduction disturbances. Prevention and troubleshooting strategies involve optimized imaging, cautious manipulation of the device, and prompt recognition of adverse events. Vascular access techniques and closure devices are reviewed to minimize access-related complications.

<strong>Case Examples and Decision Algorithm:</strong>  
Illustrative cases demonstrate practical application of imaging and procedural techniques, including management with bystander or dynamically interacting CIED leads and navigation around anatomical variants like prominent Eustachian valves. An interactive decision algorithm assists clinicians stepwise in procedural imaging assessment, right atrial steering, clip positioning, leaflet grasping, and use of additional clips.

<strong>Conclusion:</strong>  
This resource serves as an essential procedural and imaging guide for clinicians performing T-TEER with the TriClip system, emphasizing the importance of multi-modality imaging, detailed anatomical assessment, careful procedural planning, and prompt management of complications to optimize outcomes in patients with severe TR.

Keywords

Transcatheter Tricuspid Edge-to-Edge Repair

TriClip system

tricuspid regurgitation

echocardiography

3D intracardiac imaging

clip deployment techniques

cardiac implantable electronic devices

procedural complications

right atrial steering

multimodality imaging