The TriArtic procedure: TRIcuspid annular reduction by TEER in the commissure—a transcatheter annuloplasty enabling EVOQUE tricuspid valve replacement: a case report

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.

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.

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.