The patient was 77-year-old woman with a history of ischemic cardiomyopathy and severe functional mitral and tricuspid regurgitation. Two years prior, she had undergone coronary bypass surgery, mitral valve ring annuloplasty, and suture annuloplasty of the tricuspid valve (DeVega).
The patient complained of worsening heart failure symptoms, particularly peripheral edema, decreased physical capacity, and shortness of breath (New York Heart Association (NYHA) Functional Class III). Upon admission, physical examination revealed marked peripheral edema, jugular venous distension, and irregular heartbeat. The electrocardiogram showed atrial fibrillation. NT-proB-type natriuretic peptide level was 2,270 pg/mL.
Echocardiography demonstrated normal left ventricular function and mild mitral regurgitation after mitral ring annuloplasty but massive tricuspid regurgitation (vena contractae width of 15 mm) due to gradual dilation of the tricuspid annulus (diameter of 40 mm) (Supplementary Video S1). The patient was evaluated as to be at high risk for re-surgery of the tricuspid valve (EuroScore II 4.8%) and was considered for TTVr by the heart team.
TEER was performed by using the TriClip  device (Abbott, Vascular GmbH). During the TEER procedure, it was difficult to visualize the septal leaflet of the tricuspid valve in transesophageal echocardiography (TEE) due to shadowing from the annuloplasty ring on the mitral site. This was resolved by utilizing an atypically higher degree of probe rotation (Supplementary Video S2). Previous sutured annuloplasty of the tricuspid valve did not affect imaging of the valve or the procedure itself. The first device was used to grasp the anterior and septal leaflets. The second device was deployed to grasp the posterior and septal leaflets. Tricuspid regurgitation was reduced to a mild degree in postprocedural TEE (Figure 1), and in transthoracic echocardiography that was performed at the time of discharge (Supplementary Video S3). Hemodynamic improvement with slightly reduced left atrial pressure (from 12 mmHg before the procedure to 9 mmHg after the procedure) and markedly increased cardiac index (from 1.8 to 2.5 L min-1 m-2). After 1 month of follow-up, repeat echocardiography demonstrated tricuspid regurgitation grade 1 without stenosis (transvalvular gradient of 1 mmHg). The patient reported that physical capacity and dypnea had improved (to NYHA functional class I).