The ELASTA-T Technique for TTVR After Failed T-TEER: An Operator-Oriented Guide to Planning, Execution, Pitfalls

Failure of tricuspid transcatheter edge-to-edge repair (T-TEER) with persistent severe tricuspid regurgitation (TR) is an increasingly encountered clinical scenario in contemporary structural heart disease treatment. In this setting, transcatheter tricuspid valve replacement (TTVR) is emerging as an effective therapeutic option for recurrent TR after T-TEER. However, the presence of pre-existing tricuspid edge-to-edge devices significantly alters valve geometry, creating a fixed multiple-orifice configuration that may impair coaxial device crossing, generate asymmetrical expansion forces, and compromise anchoring conditions during valve implantation. ELASTA-T (Electrosurgical LAceration and STAbilization of T-TEER devices with a TTVR system) has been developed as a catheter-based strategy to selectively detach one leaflet from the T-TEER device while preserving attachment to the opposing leaflet, thereby restoring a functionally single-orifice configuration prior to valve implantation. This paper provides a comprehensive, practical, operator-oriented technical framework for performing ELASTA-T before TTVR using the EVOQUE system. The authors describe a structured approach integrating preprocedural planning to define T-TEER device position, commissural relationships, leaflet geometry, and subvalvular anatomy. Detailed step-by-step procedural guidance is provided, including dual-catheter valve crossing, snaring system creation, electrosurgical "flying V" and "flying U" wire preparation, controlled leaflet-T-TEER device laceration, and subsequent transcatheter tricuspid valve deployment. Key technical considerations, procedural pitfalls, and troubleshooting strategies are also discussed to improve safety and reproducibility. Through this structured approach, the aim of this review is to describe this emerging procedural technique and facilitate its adoption among structural heart operators.