When Right Isn't Right: Left Femoral Access for EVOQUE Transcatheter Tricuspid Valve Replacement System

As transcatheter tricuspid valve replacement with the EVOQUE system gains wider clinical adoption, growing experience has highlighted key anatomical considerations that influence procedural success. While right transfemoral (TF) access is the standard approach, it can be technically challenging in patients with complex right heart anatomy, such as low right atrium (RA) height or a large inferior vena cava-tricuspid valve annulus (IVC-TVA) offset. These factors may lead to suboptimal trajectory, impaired coaxiality, and difficult valve deployment. Left TF access offers a potential alternative by providing additional RA height and a more favorable lateral trajectory, allowing improved alignment with the tricuspid valve annulus (TVA). This approach is particularly useful in patients with large short-axis (SAX) offsets (>20 mm) or steep long-axis angles where right TF access may not achieve perpendicular orientation despite secondary catheter flexion. Using a preprocedural cardiac computed tomography angiography (CCTA) scan, anatomical factors such as RAH, leaflet tethering height, RV depth, and papillary muscle location can be evaluated to guide access planning. While left TF access introduces its own technical considerations, including venous tortuosity, excessive unwanted RA height, and increased need for primary flex, it may expand procedural feasibility in anatomically challenging cases. This review outlines real-world scenarios where left-sided access was favored, supporting its use as a safe and effective strategy in selected patients. Further studies are warranted to assess long-term outcomes and to inform the design of next-generation delivery systems capable of accommodating broader anatomical variation.