How to mirror tricuspid transcatheter edge-to-edge repair (TEER) to mitral TEER in terms of procedural imaging and device workflow: a step-by-step primer

Transcatheter edge-to-edge repair (TEER) has emerged as a pivotal therapy for mitral and tricuspid regurgitation in patients at high surgical risk. Although anatomical similarities between the mitral and tricuspid valves have allowed the use of the same clip delivery system (CDS) for both procedures, important anatomical differences and imaging challenges necessitate distinct procedural strategies. In this keynote lecture, we compare the technical aspects and imaging guidance of mitral and tricuspid TEER and highlight key maneuvers that optimize procedural success and safety. We focus on the Abbott MitraClip and TriClip systems given both are Food and Drug Administration (FDA) approved in the United States and we have extensive experience with both systems. This stepwise procedural review outlines the nuances of CDS manipulation in both mitral and tricuspid TEER, emphasizing directional response, trajectory optimization, clip alignment, leaflet grasping, and deployment techniques. Differences in imaging requirements and catheter steering are addressed with reference to transesophageal echocardiography (TEE), intracardiac echocardiography (ICE), and fluoroscopic landmarks. CDS flexion and advancement from the atrium to the valve follow similar principles in both TEER procedures; however, CDS rotation produces opposite directional effects relative to the septum. In mitral TEER, the CDS is steered from lateral to medial, whereas in tricuspid TEER, it is directed from septal to lateral. Using the Abbott MitraClip system, trajectory and orientation adjustments rely primarily on the M and + knobs for mitral TEER, and on the F and S/L knobs for tricuspid TEER. ICE serves as a critical adjunct to TEE in tricuspid TEER due to limited acoustic windows. Grasp optimization involves leaflet-specific torque and individual gripper manipulation. Mitral and tricuspid TEER require distinct navigation strategies and imaging approaches, but can be standardized and mirrored in parallel for better understanding between both procedures. Mastery of these valve-specific techniques, along with continued innovation in imaging and CDS design, will be essential to improving the safety and efficacy of tricuspid TEER.