Anterior Tilted Deployment of EVOQUE Transcatheter Tricuspid Valve Replacement System: Overcoming Inadequate Implant...

Transcatheter tricuspid valve (TV) replacement (TTVR) with the EVOQUE system is the first and only Food and Drug Administration-approved replacement option for patients with ≥ moderate tricuspid regurgitation despite optimal medical therapy. Several anatomical considerations affect procedural success. Transfemoral (TF) access is the preferred approach but can be challenging. It is influenced by the inferior vena cava (IVC)-to-tricuspid valve annulus (TVA) offset as well as the working room length. The latter combines right atrium (RA) height and right ventricle (RV) depth and is affected by the IVC-TVA distance. In cases where the right atrial height is short (<60 mm), the standard TF deployment may be hindered due to deep capsule position in the RV, which can cause chordal entanglement and affect trajectory. In such scenarios, mitigation strategies such as wire manipulation or secondary flex may be required. When those maneuvers are insufficient, left femoral venous access or transjugular (TJ) approach may be necessary. Here we describe a novel deployment technique to facilitate successful valve implantation as an added strategy to overcome lack of right atrial height while maintaining femoral access. The anterior tilted deployment strategy described here ensures optimal valve placement and function, reducing the risk of procedural complications related to limited height in the RA and the need to switch access intraprocedurally. This method highlights the adaptability of the EVOQUE system in managing complex cardiac anatomies.