Tricuspid transcatheter edge-to-edge repair in patients with cardiac implantable electronic device leads

Cardiac implantable electronic devices (CIEDs) are frequently encountered in patients undergoing transcatheter edge-to-edge repair (TEER) for severe tricuspid regurgitation (TR), with a prevalence exceeding 30%. Transvalvular leads introduce unique anatomic and procedural challenges, including imaging shadowing, leaflet tethering, device-lead interaction, and risk of entanglement during repair. Successful intervention requires careful preprocedural assessment of tricuspid valve anatomy, mechanism of TR, inferior vena cava (IVC) alignment, and the spatial relationship of right atrial, coronary sinus, right ventricular, or leadless systems to the tricuspid apparatus. This manuscript describes a structured intraoperative approach to managing CIED leads during tricuspid TEER (tTEER). The strategy incorporates multi-site femoral venous access, stiff-wire straightening techniques to correct IVC offset, and the use of a steerable sheath to achieve controlled intracardiac lead manipulation. Step-by-step technical considerations are detailed, including lead tethering, commissural repositioning, and controlled release following device deployment. This approach aims to standardize management of CIED-related challenges and provide a reproducible technique for safe and effective tTEER in this complex cohort.