Navigating multiple valvular heart disease in a patient with heart failure

To assess the suitability for Tricuspid Transcatheter Edge-to-Edge Repair (T-TEER), a TEE was performed (March 2025) (Figure 4):

• Normal RV size and function (TAPSE 23 mm, S’ TDI 14 cm/sec, FAC 47 %, RVFWLS -30 %). 
• Persistent severe secondary atrial functional TR (RAVi 78 ml/m², tenting height < 9 mm, tricuspid annulus 27 mm/m²):  
  • Anatomy: 4 leaflets morphology (Type III)
  • Jet localisation: central jet with a greater jet component between the septal/anterior leaflet
  • Coaptation gap 6-7 mm
  • Pacemaker lead positioned at the posterior commissure, thus not significantly contributing to the underlying mechanism of the TR etiology. 
  • Optimal echocardiographic view for leaflet visualisation
• Elevated sys-PAP (estimated 50 mmHg)

According to all these features, the anatomy was deemed feasible for T-TEER⁴.

T-TEER procedure (May 2025) - Figure 5

The Heart Team confirmed the indication for T-TEER.

Edge-to-edge repair was then performed:
 

• Implantation of a single TriClip XTW (Abbott Structural Heart, St Paul, MN, USA) between the anterior and septal leaflets
• Procedural success without complications 

Post-procedural echocardiogram: residual mild TR.

Clinical follow-up (June 2025)

• Asymptomatic at rest (no angina or palpitations), with significant improvement in dyspnea. 
• Hemodynamically stable (HR 52 bpm, BP 140/90 mmHg)
• TT echocardiography (Figure 6): 

• LVEF 55 %
• TAVI bioprosthesis (Navitor 29 mm): well-positioned with normal function (Max/mean gradient 8/4 mmHg), no significant intra- or paravalvular leaks
• TriClip: stable position of the clip between anterior and septal leaflets, with mild residual TR (anterograde gradient 1–2 mmHg)
• No pericardial effusion