Transcatheter Edge-to-Edge Repair of Tricuspid Regurgitation With TriClip: A Step-by-Step Guide

Tricuspid regurgitation (TR), a condition that was once thought to be of little clinical importance, is now recognized as a progressive disease associated with increased morbidity and mortality. Despite the prevalence of TR, this condition remains undertreated due to the absence of effective medical therapy and high surgical risk. However, tricuspid transcatheter edge-to-edge repair (T-TEER) using the TriClip system has emerged as a new approach, offering a minimally invasive alternative for patients with symptomatic severe TR and prohibitive surgical risk. Thus, this comprehensive review outlines a step-by-step approach to TriClip implantation, encompassing anatomical and pathophysiological foundations, patient selection criteria, imaging protocols, and procedural techniques. Emphasis is placed on the critical role of transesophageal echocardiography for device guidance, leaflet grasping, and confirmation of procedural success. Moreover, key intra-procedural challenges and troubleshooting strategies are discussed in detail, along with post-procedural management, including antithrombotic therapy, imaging surveillance, and functional assessment. Comparative insights between TriClip and the PASCAL system are provided, highlighting technical and clinical differences, as well as implications for device selection. The emerging role of combined mitral and tricuspid TEER using a single steerable guide catheter is also explored, supported by early data suggesting the safety and efficacy of this combination. Evidence from randomized trials and real-world registries supports the safety, feasibility, and durability of TriClip-based T-TEER. Notably, as experience and technology continue to evolve, T-TEER is positioned to become a cornerstone in the management of functional TR in high-risk populations.