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Part 1 | Session 3 Hybrid Guidance, Leaflet Capture, and Release
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Part 1 | Session 4 The Second Clip and Managing Lead Interference
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Part 1 | Session 5 Post-Procedure, Efficiency, and Outcomes
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Part 1 | Session 1 Case Planning, Patient Selection, and the Hybrid Strategy
In this second chapter, Dr Karim Al-Azizi (Baylor Scott & White Health – The Heart Hospital, US) demonstrates the step-by-step technical approach to TriClip tricuspid transcatheter edge-to-edge repair (TEER) using a dual-imaging strategy.
The case illustrates vascular access techniques, device positioning, and the critical role of hybrid transoesophageal echocardiography (TEE) and intracardiac echocardiography (ICE) guidance in achieving optimal anatomical alignment for successful tricuspid valve repair in this complex, high-risk patient.
Throughout the procedure, viewers will witness real-time problem-solving as the interventional team adjusts device trajectory, confirms anatomical landmarks, and employs the "straddling" manoeuvre to ensure optimal clip positioning before final deployment.
This chapter provides practical insights into how an imaging-driven strategy translates into targeted two-clip repair optimisation in a high-risk, lead-related tricuspid regurgitation case.
Key Learnings:
- Dual-Imaging Integration: Transoesophageal and intracardiac echocardiography provide superior multiplanar, real-time assessment, reducing radiation exposure and improving procedural precision.
- Perpendicularity and Stability: Achieving perpendicular device orientation and verifying trajectory through the "straddling" technique ensures successful edge-to-edge repair and complete leaflet coaptation.
- Anatomical Landmarks: Standardised three-dimensional reference points enable clear team communication and reduce procedural duration in complex structural heart cases.
In this comprehensive five-chapter case series, Dr Karim Al-Azizi (Baylor Scott & White Health – The Heart Hospital, US) presents a detailed step-by-step approach to complex tricuspid valve repair using hybrid imaging guidance.
Case Overview:
An 80-year-old woman with severe symptomatic pacemaker lead-associated tricuspid regurgitation and heart failure with preserved ejection fraction (HFpEF) undergoes successful two-device TriClip XTW transcatheter edge-to-edge repair (TEER).
Chapter 1 – Case Planning, Patient Selection, and Hybrid Strategy
Introduction to the case, patient selection criteria, and rationale for hybrid transoesophageal echocardiography (TEE) and intracardiac echocardiography (ICE) imaging strategy.
Chapter 2 – Step-by-Step Technical Approach and Device Positioning
Real-time demonstration of vascular access, device trajectory planning, clip positioning and multiplanar imaging-guided optimization. Viewers witness live problem-solving and anatomical landmark confirmation.
Chapter 3 – Pacemaker Lead Avoidance and Independent Leaflet Grasping
Detailed walkthrough of anterior device placement relative to the pacemaker lead, transgastric TEE confirmation, high-resolution leaflet assessment and meticulous independent grasping of lateral and septal leaflets.
Chapter 4 – Two-Device Strategy for Pacemaker Lead-Adjacent Residual Regurgitation
Complex implantation of a second TriClip XTW device to address residual jets, posterior positioning relative to the lead, stepwise leaflet capture with clip arm testing and final device stability assessment.
Chapter 5 – Post-Procedure, Efficiency, and Outcomes
Final assessment demonstrating haemodynamic stability, mild residual regurgitation, efficient sub-50-minute procedure time, safe access-site closure, next-day discharge and 30-day clinical follow-up showing Kansas City Cardiomyopathy Questionnaire improvement (42 to 78) with preserved right ventricular function.
Key Learning Points:
- Comprehensive hybrid imaging protocol for complex tricuspid TEER
- Patient selection and risk stratification in frail, high-risk populations
- Pacemaker lead avoidance techniques and anatomical considerations
- Two-device repair strategy for residual regurgitation
- Procedural efficiency benchmarks and quality-of-life outcomes
Faculty:
Surgeon: Dr Karim Al-Azizi
Imaging: Dr Ralph Matar
Anaesthesiologist: Dr Jason Evan Smith
Co-surgeon: Dr Lee Hafen
Fellow: Dr Ahmed Elkaialy
Producer: Transcatheter Academy
Editor: Mirjam Boros
More from this programme
Part 1
Faculty Biographies
Karim Al-Azizi
Interventional Cardiologist and Structural Heart Disease Specialist
Dr Karim Al-Azizi is an Interventional Cardiologist and Structural Heart Disease specialist at Baylor Scott & White Health - The Heart Hospital, Texas, USA. He serves as the Medical Director of the Structural Heart Program and the Cardiac Catheterization Laboratories. He serves as the Program Director of the Structural Heart Disease Fellowship.
His clinical and research interests include structural heart disease, transcatheter interventions for valvular heart disease, and electrosurgery. He speaks at national and international conferences on these subjects and serves as a principal investigator on multiple clinical trials in structural heart disease.
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