Management of Single Leaflet Device Attachment in the Tricuspid Position.

Background: Single leaflet device attachment (SLDA) during transcatheter edge-to-edge repair (TEER) of the tricuspid valve is an uncommon but recognized complication. This case series presents 2 older adult patients with symptomatic severe tricuspid regurgitation who underwent tricuspid TEER and experienced SLDA during the procedure.

Case Series: The first patient was an 85-year-old man with liver cirrhosis and right-sided heart failure. Transthoracic echocardiography (TTE) revealed severe tricuspid regurgitation secondary to annular dilation, with a coaptation gap of 5 mm between the anterior and septal leaflets. He was deemed a high operative risk and underwent tricuspid TEER (tTEER) using 2 MitraClip XTW devices (Abbott). During the procedure, 1 clip detached from the septal leaflet and was retrieved using EN Snare (Merit Medical) and ŌNŌ (ŌNŌ COR) devices, with placement of another clip. The procedure ultimately reduced tricuspid regurgitation from massive to moderate. The second patient was a 70-year-old woman with a history of atrial fibrillation and rheumatoid arthritis. She presented with symptomatic severe secondary tricuspid regurgitation on both TTE and transesophageal echocardiography. The tTEER procedure was performed using a XTW TriClip (Abbott). Following SLDA, the clip was retrieved using the EN Snare and ŌNŌ devices, and 2 subsequent clips were placed successfully, thus reducing regurgitation to mild.

Conclusions: SLDA during tTEER presents a significant procedural challenge but can be managed effectively with clip retrieval using the EN Snare and ŌNŌ devices. Both cases demonstrated successful clip retrieval without injury to the valve leaflets and successful TEER.