Effect of Clover versus Zipping on Annular Geometry and Dynamics in Tricuspid Edge-to-Edge Repair

Q: What is the clinical evidence from this study?

Population: Functional tricuspid regurgitation and right ventricular failure (n=10). Intervention: Tricuspid edge-to-edge repair (TEER) using Clover configuration vs. Pre-clipping baseline (and comparison with Zipping configuration using two clips between septal and anterior leaflets). Primary outcome: Tricuspid annular septal-lateral diameter (mm) with Clover technique (MD -3.0 mm, p=0.001).

Q: What does this research mean for the field?

In tricuspid transcatheter edge-to-edge repair, the Clover configuration produces an acute annuloplasty effect by selectively reducing annular septal-lateral diameter, whereas the Zipping configuration does not. Novelty: ClaimNovelty.CONFIRMATORY. Consensus alignment: ConsensusAlignment.SUPPORTS_CONSENSUS.

Magda Piekarska; Tomasz Stącel; Collin E. Haese; Dominika Sandel; Trace G. LaRue; Diego Guajardo; Austin Goodyke; Marcin Malinowski; Manikantam Gaddam; Ali Saker; Manuel K. Rausch; Tomasz A. Timek

doi:10.64898/2026.10.25.761672

October 28, 2026

Effect of Clover versus Zipping on Annular Geometry and Dynamics in Tricuspid Edge-to-Edge Repair

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Key result

Clover tricuspid edge-to-edge repair acutely reduces septal-lateral annular diameter by ~3 mm.

MD -3.0 mm
P=0.001
n=10

Why the study?

Transcatheter edge-to-edge repair reduces tricuspid regurgitation with some patients showing an additional annuloplasty effect, motivating comparison of the Clover versus Zipping clip configurations on tricuspid annular geometry and dynamics.

Does the Clover configuration compared to the Zipping configuration improve acute tricuspid regurgitation reduction and tricuspid annular septal-lateral diameter reduction in an ovine model of functional tricuspid regurgitation?

Key Points

To evaluate and compare the acute effects of Clover versus Zipping edge-to-edge repair configurations on tricuspid annular geometry and dynamic function.
Ten adult sheep underwent pulmonary artery banding to induce right ventricular failure and functional tricuspid regurgitation.
Six weeks later, sonomicrometry crystals were implanted around the tricuspid annulus, and two Abbott XTW clips were placed in either a Zipping (n=5) or Clover (n=5) configuration.
Echocardiographic and sonomicrometry measurements were recorded before and after clipping; one animal in the Zipping group experienced clip dislocation, leaving four available for annular dynamic analysis.
Leaflet approximation with two clips across all animals significantly reduced tricuspid regurgitation severity from 3.6+/-0.5 to 1.3+/-1.1 (p=0.01) and right ventricular diameter from 26.6±2.8 to 20.7±4.8 mm (p=0.01).
Septal-lateral annular diameter decreased overall from 29.2+/-2.2 to 26.7+/-2.9 mm (p=0.01), with a significant reduction occurring only in the Clover cohort (30+/-2 to 27+/-1 mm; p=0.001) compared with Zipping (28±2.5 to 26±4.6 mm, p=0.36).

Structured PICO

Does the Clover configuration compared to the Zipping configuration improve acute tricuspid regurgitation reduction and tricuspid annular septal-lateral diameter reduction in an ovine model of functional tricuspid regurgitation?

P

Population

10 adult intact male Dorset sheep with right ventricular failure and moderate-to-severe functional tricuspid regurgitation induced by 6 weeks of pulmonary artery banding, evaluated acutely before and after clip implantation.

I

Intervention

Tricuspid edge-to-edge leaflet approximation using two Abbott G4 XTW clips placed in the Clover configuration (n=5), approximating the septal leaflet to both the anterior leaflet and the posterior leaflet under direct vision via open right atrium on cardiopulmonary bypass.

C

Comparator

Tricuspid edge-to-edge leaflet approximation using two Abbott G4 XTW clips placed in the Zipping configuration (n=5), with both clips approximating the septal and anterior leaflets under direct vision via open right atrium on cardiopulmonary bypass, as well as pre-clipping baseline measurements.

O

Outcome

Acute change in tricuspid regurgitation (TR) severity grade (0-4 scale via epicardial echocardiography) and tricuspid annular geometry, size (including septal-lateral annular diameter, area, and perimeter), and dynamics assessed via 3D sonomicrometry crystals immediately following clip implantation.surrogate

Main Result

Mean Difference: -3

Absolute Event Rate: 27% vs 30%

p-value: p=0.001

In an ovine model of functional tricuspid regurgitation, both Clover and Zipping edge-to-edge repair techniques reduced tricuspid regurgitation, but only the Clover configuration produced a significant acute annuloplasty effect by reducing septal-lateral annular diameter while preserving annular contraction.

Limitations

Ovine model of functional tricuspid regurgitation and right ventricular dysfunction was induced rapidly over 6 weeks by pulmonary artery banding, departing from the multi-year clinical evolution in humans.
Small sample size (10 sheep total; 5 in Clover group and 4 analyzable in Zipping group due to 1 clip dislocation).
Clips were placed under direct vision in an open beating heart on cardiopulmonary bypass rather than percutaneously.
Only acute intra-operative hemodynamic and geometric effects were assessed.
Ovine model of FTR and RV dysfunction induced over 6 weeks departs from clinical evolution over years and did not match clinical levels of chamber dilation or torrential TR
Clips were implanted through an opened atrium while on cardiopulmonary bypass, adding a physiologic insult not seen clinically
Uniformly Type 1 leaflet anatomy in animals does not reflect clinical variability (e.g., Type IIIb anatomy)
Low number of animals (n=10 total, n=4 analyzed in Zipping group due to clip dislocation)
Only acute intra-procedural effects were assessed, and only male sheep were used

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Implication

Clover configuration may confer additional annular reduction in functional TR; hypothesis-generating for technique selection pending human data.

Abstract

Introduction: Transcatheter edge-to-edge repair effectively reduces tricuspid regurgitation (TR), with some patients showing an additional 'annuloplasty effect'. Methods: Ten adult sheep underwent pulmonary artery banding to induce right ventricular failure and functional TR. Six weeks later, sonomicrometry crystals were implanted around the tricuspid annulus (TA). Two Abbott XTW clips were then placed using either a Zipping (n=5) or Clover (n=5) configuration. Echocardiographic and sonomicrometry data were collected before and after clip implantation to assess TA geometry and function. Results: The model produced right ventricular dilation, dysfunction, and moderate-to-severe functional TR. In all animals, leaflet approximation with two clips significantly reduced TR severity (3.6+/-0.5 to 1.3+/-1.1; p=0.01) and septal-lateral annular diameter (29.2+/-2.2 to 26.7+/-2.9 mm; p=0.01). However, a significant reduction in septal-lateral annular diameter occurred only with the Clover technique (30+/-2 to 27+/-1 mm; p=0.001). Conclusions: Both techniques reduced TR, but only the Clover configuration produced an acute annuloplasty effect by selectively decreasing septal-lateral annular diameter.

Discussion

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Cite This Study

Piekarska et al. (2026) studied Functional tricuspid regurgitation and right ventricular failure (n=10). Tricuspid edge-to-edge repair (TEER) using Clover configuration vs. Pre-clipping baseline (and comparison with Zipping configuration using two clips between septal and anterior leaflets) was evaluated on Tricuspid annular septal-lateral diameter (mm) with Clover technique (MD -3.0 mm, p=0.001). Clover configuration tricuspid edge-to-edge repair acutely reduced tricuspid annular septal-lateral diameter from 30±1.5 to 27±0.8 mm and TR grade from 3.8±0.4 to 1.1±0.5.

synapsesocial.com/papers/6ae43383d9418cd7c8f4645e https://doi.org/10.64898/2026.10.25.761672

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Effect of Clover versus Zipping on Annular Geometry and Dynamics in Tricuspid Edge-to-Edge Repair

Key Points

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Effect of Clover versus Zipping on Annular Geometry and Dynamics in Tricuspid Edge-to-Edge Repair

Key Points

Structured PICO

Main Result

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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