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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
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Part 1 | Session 3 Hybrid Guidance, Leaflet Capture, and Release
In this fourth chapter, Dr Karim Al-Azizi demonstrates a complex TriClip XTW tricuspid edge-to-edge repair using a second device to treat pacemaker lead-associated tricuspid regurgitation.
The case focuses on advancing the additional clip from the superior vena cava into the tricuspid inflow, optimising catheter flexion and rotation, and positioning the device just posterior to the pacemaker lead to target the residual jet whilst preserving valve function.
Viewers follow a structured workflow beginning with careful advancement and "straddling" of the second device, then using mid-oesophageal and transgastric TEE, 3D views and ICE to confirm a perpendicular trajectory to the annulus and clip orientation around the 3–9 (2:30–8:30) axis. Under continuous hybrid imaging, the team fine-tunes anterior–posterior translation, stabilises the ICE catheter and maintains the "no movement without leaflet visualisation" rule to navigate precisely at leaflet level next to the lead.
The procedure highlights stepwise leaflet capture with testing of clip arms and grippers, controlled advance just below the valve and meticulous grasping of septal and lateral leaflets despite lead-related impingement.
Final stages include confirmation of robust leaflet insertion and low tricuspid gradients, assessment of mild residual regurgitation near the pacemaker lead, fluoroscopic and ICE verification of clip position and stability, and safe lock release and device detachment.
Key Learnings:
- Two-Device TriClip Strategy: How to plan and execute a second TriClip XTW implantation to treat residual tricuspid regurgitation adjacent to a pacemaker lead whilst maintaining tricuspid valve function.
- Hybrid Imaging for Positioning: How coordinated mid-oesophageal and transgastric TEE, 3D views and ICE guide perpendicular trajectory, 3–9/2:30–8:30 clip orientation and precise posterior positioning relative to the lead.
- Leaflet Capture Next to a Lead: Practical techniques for optimising imaging, stabilising catheters and ensuring sufficient septal and lateral leaflet insertion before final closure and 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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