In this chapter of ICE and TEE Guidance for TriClip Tricuspid TEER, Dr Karim Al-Azizi (Baylor Scott & White Health – The Heart Hospital, US) demonstrates the step-by-step technical approach to TriClip tricuspid transcatheter edge‑to‑edge repair (TEER) using a dual‑imaging strategy.

The case highlights vascular access techniques, device positioning, and the pivotal role of hybrid transoesophageal echocardiography (TEE) and intracardiac echocardiography (ICE) in achieving precise anatomical alignment for a successful tricuspid valve repair in a complex, high‑risk patient.

Viewers follow the interventional team’s real‑time decision‑making as they refine device trajectory, identify key anatomical landmarks, and utilise the “straddling” manoeuvre to ensure optimal clip orientation before final deployment. This chapter offers practical insights into how an imaging‑guided strategy enables targeted, two‑clip repair optimisation in challenging lead‑related tricuspid regurgitation.

Key learning points:

• Dual‑imaging integration: Combining TEE and ICE provides complementary, multiplanar real‑time visualisation, minimising radiation exposure and enhancing procedural accuracy.
• Perpendicularity and stability: Maintaining perpendicular device orientation and confirming trajectory with the “straddling” technique promote complete leaflet coaptation and procedural success.
• Anatomical landmarks: Standardised three‑dimensional reference points improve team communication and reduce procedural time in complex structural interventions.