In this chapter of ICE and TEE Guidance for TriClip Tricuspid TEER, Dr Karim Al-Azizi (Baylor Scott & White Health – The Heart Hospital, US) leads a detailed TriClip tricuspid edge‑to‑edge repair, focusing on precise device placement anterior to a pacemaker lead using fluoroscopy, transgastric transoesophageal echocardiography (TEE), and intracardiac echocardiography (ICE). The case emphasises optimising device orientation, independent arm manipulation, and controlled leaflet grasp in a complex lead‑associated tricuspid regurgitation setting.

The workflow begins with transgastric TEE to verify device trajectory and alignment, followed by ICE for high‑resolution visualisation of leaflet anatomy and the device–lead interface. Using 3D navigation, X‑plane imaging, and digital steering, the team aligns the clip arms parallel to the tricuspid annulus, advances the system below the valve, and carefully opens the arms to capture the anterior and septal leaflets.

The procedure demonstrates precise independent grasping of lateral and septal leaflets, frequent checks of leaflet insertion depth and clip position, and fine adjustments when the initial grasp is suboptimal. In the final stages, the team confirms a firm tissue bridge, validates clip arm position fluoroscopically, performs lock testing, reassesses residual regurgitation and haemodynamics, and safely retrieves the delivery system after secure device release.
 

Key learning points:

• Hybrid imaging with transgastric TEE and ICE: Enables accurate trajectory planning, real‑time confirmation that the clip remains anterior to the pacemaker lead, and detailed assessment of leaflet insertion.
• Independent grasping of lateral and septal leaflets: Facilitates precise control of capture depth and minimises the risk of single‑leaflet attachment in delicate tricuspid tissue.
• Structured 3D navigation and iterative imaging checks: Ensure durable tissue bridging, effective anterior jet reduction, and stable device positioning before final release.