In this chapter of ICE and TEE Guidance for TriClip Tricuspid TEER, Dr Karim Al‑Azizi showcases a complex TriClip XTW tricuspid edge‑to‑edge repair using a second device to address 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 effectively treat the residual jet while preserving valve function.

Viewers follow a structured workflow beginning with careful advancement and “straddling” of the second device, followed by coordinated mid‑oesophageal and transgastric TEE, 3D imaging, and ICE to confirm a perpendicular trajectory to the annulus and correct clip orientation along the 3–9 (2:30–8:30) axis. Under continuous hybrid imaging, the team fine‑tunes anterior–posterior positioning, stabilises the ICE catheter, and adheres to the “no movement without leaflet visualisation” rule to ensure precise leaflet‑level navigation near the lead.

The procedure demonstrates stepwise leaflet capture, including clip arm and gripper testing, controlled advancement beneath the valve, and meticulous grasping of the septal and lateral leaflets despite minor lead impingement. In the final stages, the team confirms robust leaflet insertion, low tricuspid gradients, and only mild residual regurgitation near the lead, followed by fluoroscopic and ICE confirmation of clip stability, safe lock release, and detachment.
 

Key learnings:

• Two‑device TriClip strategy: Planning and deploying a second TriClip XTW to treat residual tricuspid regurgitation adjacent to a pacemaker lead while maintaining optimal valve function.
• Hybrid imaging for positioning: Coordinated use of mid‑oesophageal and transgastric TEE, 3D imaging, and ICE to 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 adequate septal and lateral leaflet insertion before final closure and device release.