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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
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Part 1 | Session 2 System Insertion and Trajectory Optimisation
In this third chapter, Dr Karim Al-Azizi (Baylor Scott & White Health – The Heart Hospital, US) guides a detailed TriClip tricuspid edge-to-edge repair focused on placing the device anterior to a pacemaker lead using fluoroscopy, transgastric TEE and intracardiac echocardiography (ICE). The case centres on optimising device orientation, independent arm manipulation and controlled leaflet grasp in a complex lead-associated tricuspid regurgitation scenario.
Viewers follow a stepwise workflow beginning with transgastric TEE to confirm trajectory and orientation, then switching to ICE for high-resolution assessment of leaflet tissue and device–lead relationship. Using 3D navigation, X-plane imaging and digital steering, the team aligns the clip arms with the tricuspid annulus, advances the system below the valve and gently opens the arms to allow anterior and septal leaflets to fall into the device.
The procedure highlights meticulous independent grasping of lateral and septal leaflets, repeated checks of leaflet insertion depth and clip position, and careful adjustment when initial capture is suboptimal.
Final stages include verification of a robust tissue bridge, fluoroscopic confirmation of clip arm position, lock testing, assessment of residual jets and haemodynamic stability, and safe retrieval of the delivery system once the device is fully released.
Key Learnings:
- Hybrid Imaging with Transgastric TEE and ICE: Supports accurate trajectory planning, real-time verification that the clip remains anterior to the pacemaker lead, and high-resolution assessment of leaflet insertion.
- Independent Grasping of Lateral and Septal Leaflets: Allows fine-tuning of capture depth, minimising the risk of single-leaflet attachment in thin tricuspid tissue.
- Structured 3D Navigation and Repeated Imaging Checks: During crossing, grasping and closure, ensure a durable tissue bridge, reduction of the anterior jet and stable device position before full release.
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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