Hybrid imaging approach for guidance of transcatheter tricuspid valve replacement with Evoque system for lead-associated type B atrial tricuspid valve regurgitation.

Tricuspid regurgitation (TR) continues to provide a substantial clinical challenge, especially in high-risk patients with severe symptoms. Transcatheter tricuspid valve replacement (TTVR) has recently emerged as a potential and novel therapy option for individuals with at least severe TR. However, the success of TTVR depends heavily on appropriate imaging guidance, with transesophageal echocardiography (TEE) serving as the gold standard for evaluating tricuspid valve morphology and directing device location. Here we present a rare case of a 74-year-old female with lead-associated type B atrial TR who had successful TTVR utilizing the EVOQUE device (Edwards Lifesciences, Irvine, CA, USA). Because TEE image quality was unsatisfactory throughout the procedure, we demonstrate the use of a hybrid imaging technique combining TEE with transthoracic echocardiography and multiplanar reconstruction to guide EVOQUE implantation. Learning objective: This case highlights the importance of multimodality imaging during pre-procedural planning in patients with complex tricuspid regurgitation and potential guiding image view obstacles. Alternative imaging modality should be selected primarily based on the anatomy. Non-invasive methods such as three-dimensional transthoracic echocardiography may serve as bailout strategies or, in selected anatomies, as complementary tools for guiding transcatheter tricuspid valve interventions when standard transesophageal echocardiography is limited or contraindicated.