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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
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Part 1 | Session 4 The Second Clip and Managing Lead Interference
In this closing chapter, Dr Karim Al-Azizi (Baylor Scott & White Health – The Heart Hospital, US) demonstrates the final assessment and outcomes of an 80-year-old woman with pacemaker-associated tricuspid regurgitation treated with a two-device TriClip XTW repair. With one clip positioned anterior and one posterior to the pacemaker lead, he reviews haemodynamic stability, confirms only mild residual regurgitation on echocardiography and outlines access-site closure and post-procedural care, culminating in next-day discharge and marked symptomatic improvement at 30 days.
Dr Al-Azizi highlights how a streamlined hybrid imaging algorithm and efficient team communication can reduce procedure time to under 50 minutes whilst achieving durable reduction of tricuspid regurgitation, preserved right ventricular function and substantial gains in quality of life (Kansas City Cardiomyopathy Questionnaire score: 42 to 78). This outcome-focused walkthrough offers practical benchmarks for interventional and imaging cardiologists managing similar complex lead-associated tricuspid valve disease.
Key Learnings:
- Post-Implant Residual Tricuspid Regurgitation Assessment: How to evaluate residual tricuspid regurgitation after two-clip TriClip repair, ensuring only mild jets remain around the pacemaker lead with stable blood pressure and gradients.
- Procedural Efficiency and Access Management: How coordinated imaging and venous-access closure strategies support sub-60-minute procedure times, safe extubation in the lab and next-day discharge in high-risk elderly patients.
- Clinical and Echocardiographic Follow-up: How to interpret 30-day transthoracic echocardiography findings, correlate them with improvements in Kansas City Cardiomyopathy Questionnaire score, dyspnoea and oedema, and use these metrics to define procedural success in advanced tricuspid valve disease.
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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