The TriArtic procedure: TRIcuspid annular reduction by TEER in the commissure-a transcatheter annuloplasty enabling EVOQUE tricuspid valve replacement: a case report.
- 1Department of Cardiology, Pulmonology, and Vascular Medicine, University Hospital Düsseldorf, Medical Faculty of the Heinrich Heine University Düsseldorf, 40225 Düsseldorf, Germany.
- 2Cardiovascular Research Institute Düsseldorf (CARID), Medical Faculty, Heinrich-Heine University, 40225 Düsseldorf, Germany.
Abstract
Background
Transcatheter tricuspid valve replacement (TTVR) with the EVOQUE system has expanded therapeutic options for severe tricuspid regurgitation (TR), but a prohibitively dilated tricuspid annulus may exceed the device-sizing matrix and preclude implantation. No transcatheter strategy has been described to mechanically pre-condition such an annulus.Case summary
A 71-year-old woman with heart failure with reduced ejection fraction (left ventricular ejection fraction 38%, suspected premature-ventricular-complex-induced cardiomyopathy), permanent atrial fibrillation, and class III obesity presented with torrential atrial functional TR refractory to fully optimized guideline-directed medical therapy. Screening cardiac computed tomography (CT) classified the native annulus as 'outside parameters' for the 56 mm EVOQUE (Edwards Lifesciences); the Heart Team also deemed standalone tricuspid edge-to-edge repair (T-TEER) inadequate owing to the massively dilated annulus. We performed the TriArtic procedure-a single TriClip XTW (Abbott) deployed in the septo-anterior position as a transcatheter annuloplasty step. Repeat CT after 27 days demonstrated an ∼11% reduction in tricuspid annular area and conversion of projected-derived-diameter oversizing from -2.9% to +3.3% (within parameters). Transfemoral EVOQUE 56 mm was implanted 48 days after the TriClip; postprocedural imaging confirmed no residual regurgitation and a mean transtricuspid gradient of 1 mm Hg, with rapid recovery of cardiorenal function.Discussion
Transcatheter tricuspid annuloplasty by a strategically placed commissural TEER device may convert a prohibitively dilated annulus into one within EVOQUE-implantable parameters. In carefully selected patients ineligible for either standalone strategy, sequential transcatheter annuloplasty followed by valve replacement-the TriArtic procedure-may offer a feasible pathway, conceptually analogous to the mitral ARCTIC technique. This single case demonstrates feasibility only and does not establish general applicability.
Related
- Coexisting Moderate-to-Severe Tricuspid Regurgitation and Renal Dysfunction Identify a High-Risk Group After Transcatheter Aortic Valve Replacement
- Electrosurgical Clip Laceration to Facilitate Transcatheter Tricuspid Valve Replacement After Suboptimal Edge-To-Edge Repair
- Transcatheter aortic valve replacement in bicuspid versus tricuspid aortic valves among patients with mixed aortic valve disease
- Percutaneous closure of ruptured sinus of Valsalva and tricuspid paravalvular leak following surgical tricuspid valve replacement.
- Impact of Tricuspid Regurgitation on Outcomes After Transcatheter Edge-to-Edge Repair for Primary Mitral Regurgitation: The PRIME-MR Registry
BibTeX
@article{phinicarides2026triartic,
title = {{The TriArtic procedure: TRIcuspid annular reduction by TEER in the commissure-a transcatheter annuloplasty enabling EVOQUE tricuspid valve replacement: a case report.}},
author = {Raphael Phinicarides and Fabian Voß and Tobias Zeus and Amin Polzin},
journal = {European heart journal. Case reports},
year = {2026},
month = oct,
doi = {10.1093/ehjcr/ytag729},
url = {https://europepmc.org/article/MED/42898779},
note = {CC BY},
}
RIS
TY - JOUR
TI - The TriArtic procedure: TRIcuspid annular reduction by TEER in the commissure-a transcatheter annuloplasty enabling EVOQUE tricuspid valve replacement: a case report.
AU - Raphael Phinicarides
AU - Fabian Voß
AU - Tobias Zeus
AU - Amin Polzin
PY - 2026
DA - 2026/10/06
JO - European heart journal. Case reports
DO - 10.1093/ehjcr/ytag729
UR - https://europepmc.org/article/MED/42898779
AB - Background Transcatheter tricuspid valve replacement (TTVR) with the EVOQUE system has expanded therapeutic options for severe tricuspid regurgitation (TR), but a prohibitively dilated tricuspid annulus may exceed the device-sizing matrix and preclude implantation. No transcatheter strategy has been described to mechanically pre-condition such an annulus.Case summary A 71-year-old woman with heart failure with reduced ejection fraction (left ventricular ejection fraction 38%, suspected premature-ventricular-complex-induced cardiomyopathy), permanent atrial fibrillation, and class III obesity presented with torrential atrial functional TR refractory to fully optimized guideline-directed medical therapy. Screening cardiac computed tomography (CT) classified the native annulus as 'outside parameters' for the 56 mm EVOQUE (Edwards Lifesciences); the Heart Team also deemed standalone tricuspid edge-to-edge repair (T-TEER) inadequate owing to the massively dilated annulus. We performed the TriArtic procedure-a single TriClip XTW (Abbott) deployed in the septo-anterior position as a transcatheter annuloplasty step. Repeat CT after 27 days demonstrated an ∼11% reduction in tricuspid annular area and conversion of projected-derived-diameter oversizing from -2.9% to +3.3% (within parameters). Transfemoral EVOQUE 56 mm was implanted 48 days after the TriClip; postprocedural imaging confirmed no residual regurgitation and a mean transtricuspid gradient of 1 mm Hg, with rapid recovery of cardiorenal function.Discussion Transcatheter tricuspid annuloplasty by a strategically placed commissural TEER device may convert a prohibitively dilated annulus into one within EVOQUE-implantable parameters. In carefully selected patients ineligible for either standalone strategy, sequential transcatheter annuloplasty followed by valve replacement-the TriArtic procedure-may offer a feasible pathway, conceptually analogous to the mitral ARCTIC technique. This single case demonstrates feasibility only and does not establish general applicability.
SN - 2514-2119
ER -