Transjugular Transcatheter Tricuspid Valve Replacement With the Evoque System

Abstract

Transcatheter tricuspid valve replacement (TTVR) with the Evoque tricuspid valve replacement system using a transfemoral (TF) approach has demonstrated safety and efficacy in patients with severe symptomatic tricuspid regurgitation. However, anatomical constraints may preclude TF delivery, necessitating alternative approaches. We present a step-by-step guide for performing TTVR via the transjugular (TJ) route based on 2 successful cases. In the first case, TJ access was selected upfront owing to the presence of an Adams-DeWeese inferior vena cava clip, which created a mechanical obstruction to femoral access. In the second case, TF access was attempted but abandoned owing to unfavorable trajectory, making valve deployment unsuccessful despite attempts from both the right and left femoral veins. This guide provides detailed procedural steps, technical considerations, and an algorithm for patient selection to help operators successfully perform TJ TTVR when TF access is not suitable.

Graphical Abstract

Transcatheter tricuspid valve replacement (TTVR) with the Evoque system (Edwards Lifesciences) has emerged as an effective treatment for severe symptomatic tricuspid regurgitation (TR), demonstrating superiority over medical therapy.^1,2 Although transfemoral (TF) access is the preferred approach, it may not be feasible in all patients owing to specific anatomical constraints.³ TTVR via a transjugular (TJ) approach is a potential alternative in selected patients.^3,4 However, the technical aspects and advantages of this alternative access route have not been fully established. Several anatomical considerations may necessitate consideration of TJ access for TTVR. Based on our experience with 2 successful cases, this step-by-step guide provides a systematic approach to TJ TTVR, aiming to expand the treatable population by helping operators confidently perform TJ TTVR when anatomical constraints limit traditional TF access options.

Take-Home Messages

• •Transjugular access can be a practical and effective alternative to transfemoral routes for patients with unfavorable femoral or inferior vena cava anatomy undergoing Evoque TTVR.
• •A low threshold for transjugular access should be considered for specific anatomies that are suboptimal for a transfemoral approach.

Step-by-Step Procedural Guide to TJ TTVR

Step 1: patient selection and preprocedural planning

Anatomical assessment

• •
  Perform transesophageal echocardiography (TEE) and cardiac computed tomography (CT) to evaluate:

  • ◦
    Right atrial (RA) systolic height (threshold: 55-60 mm minimum, <100 mm maximum)
  • ◦
    Inferior vena cava (IVC) patency and diameter (must accommodate 28-F system)
  • ◦
    IVC-to–tricuspid valve annulus (TVA) offset (<10 mm preferred)
  • ◦
    Iliac/femoral vein tortuosity
  • ◦
    TVA dimensions for valve sizing

Anatomical considerations for TJ approach

• •IVC occlusion (eg, IVC filters, clips)
• •Insufficient RA height (<60 mm in systole)
• •Insufficient RA + right ventricle (RV) working room (<90 mm systole and diastole)
• •Excessive RA height (>100 mm in systole)∗
• •Unfavorable trajectory (eg, iliac vein tortuosity, inability to optimize with the Evoque delivery system)
• •Significant IVC-to-TVA offset (>10 mm)
• •Failed TF approach

∗Limited clinical experience exists with this anatomical scenario, and the ability to overcome this constraint using the TJ approach requires further investigation and clinical validation.

Step 2: procedural setup

Room configuration

• •Position C-arm for optimal views
• •TEE and anesthesia equipment positioned for left or right TJ access
• •Sterile field extending from neck to groin (Figure 1)

Figure 1.

Procedural Setup for Transjugular TTVR

Catheterization laboratory setup optimized for left TJ TTVR with the Evoque system. (A) Patient positioning demonstrating access via the left internal jugular vein, with appropriate sterile draping and positioning to facilitate a TJ approach. The patient's head is turned to the right to optimize access to the left internal jugular vein while maintaining airway management for general anesthesia. (B) Lateral view of the catheterization laboratory showing the C-arm fluoroscopy system positioned to provide optimal visualization for TJ valve deployment. The imaging system is configured to accommodate the different trajectory and working angles required for the TJ approach. (C) Wide-angle view of the procedural setup highlighting the integrated imaging systems, including fluoroscopy and echocardiography equipment, sterile field organization, and team positioning optimized for TJ workflow. The echocardiography system is positioned to provide continuous TEE guidance throughout the procedure, which is critical for successful valve positioning and deployment. Schematic diagrams of the optimal room setup for (D) left and (E) right internal jugular access showing equipment positioning, personnel placement, and workflow optimization with TEE system and anesthesia. TEE = transesophageal echocardiography; TJ = transjugular; TTVR = transcatheter tricuspid valve replacement.

Patient positioning

• •Supine with head turned and secured opposite the side used for TJ access
• •Consider a slight Trendelenburg to engorge the jugular veins
• •Shoulder roll if needed to optimize imaging or access as needed

Step 3: vascular access

Initial access

• •Ultrasound-guided micropuncture access of the selected internal jugular vein
• •Insert 8-F sheath
• •Deploy 2 Perclose sutures in preclose fashion
• •Femoral access for intracardiac echocardiography (ICE), if needed

Wire positioning

• •Advance 8.5-F steerable sheath to RA
• •Cross the tricuspid valve and position a 0.035-inch Safari wire (Boston Scientific) in the RV apex under TEE guidance
• •Confirm a stable wire position that is free of chords or papillary muscle

Step 4: delivery system insertion

Sequential dilation

• •Remove the steerable sheath over the Safari wire
• •Sequentially dilate to 28-F
• •Advance the Evoque delivery system into the RA

System positioning

• •Orient the delivery system using fluoroscopy and TEE
• •Flex toward the tricuspid valve
• •Carefully cross into the RV
• •Secure to the table-mounted stabilizer

Step 5: valve deployment—key technical considerations for TJ approach

Understanding reversed mechanics

From the TJ approach, the controls are reversed:

• •Primary flexion: anterior/posterior movement
• •Clockwise rotation: lateral movement
• •Counter-clockwise: septal movement
• •Advancing: posterior movement
• •Withdrawing: anterior movement⁴ (Figure 2)

Figure 2.

Evoque Delivery System Manipulation From a Transjugular Approach

The figures illustrate the Evoque delivery system manipulation techniques specific to the transjugular approach: (A) primary flexion control, (B) advance/retract control, and (C) rotational control (clockwise/counter-clockwise). Secondary flexion is rarely used given a higher risk of septal bias from the transjugular trajectory. A = anterior; CCW = counter-clockwise; CW = clockwise; IVC = inferior vena cava; P = posterior; RV = right ventricle; S = septal; SVC = superior vena cava.

Optimization phase

• •Adjust depth to position the valve at annular plane
• •Optimize trajectory using TEE/ICE and fluoroscopy
• •Ensure coaxial alignment with TVA

Step 6: staged valve release

Anchor deployment

• •Rotate the capsule knob serially to 90° (ie, anchors parallel to annulus)
• •Confirm optimal positioning on TEE/ICE
• •Complete anchor release toward RA
• •Verify leaflets are not pinned

Ventricular expansion

• •Perform staged expansion while maintaining leaflet capture
• •Monitor for proper seating on TEE/ICE
• •Adjust depth as needed

Atrialization

• •Bring valve to annular plane
• •Perform final trajectory optimization
• •Expand atrial portion gradually
• •Confirm anchor tips contact annulus throughout the cardiac cycle

Final deployment

• •Retract the tapered tip into the valve
• •Rotate the release knob to a hard stop
• •Carefully remove the delivery system

Step 7: postdeployment assessment

Immediate evaluation

• •TEE assessment of valve position and function
• •Measure residual TR and transvalvular gradients
• •Evaluate for pericardial effusion
• •Assess conduction system

Hemostasis

• •Remove the delivery system carefully
• •Tighten predeployed Perclose sutures
• •Place figure-of-eight stitch
• •Apply manual pressure as needed

Step 8: postprocedural care

• •Extubation when appropriate (ideally on the table)
• •Telemetry and remote monitoring (as needed based on underlying before and after ECG)
• •TTE before discharge
• •Anticoagulation per institutional protocol

Case 1

An 80-year-old woman with a history of lower extremity deep venous thrombosis and an in situ Adams-DeWeese IVC clip was evaluated for severe TR. TEE revealed a type IIIb quadricuspid tricuspid valve with torrential primary TR (effective regurgitant orifice area: 1.7 cm²) due to a flail posterior leaflet (Supplemental Figure 1, Video 1). Cardiac CT showed a borderline RA systolic height of 50.9 mm (below the >60 mm threshold for TF access) and confirmed severe IVC narrowing (<7 mm) from the Adams-DeWeese clip (Figure 3), precluding passage of the 28-F Evoque delivery system. The diastolic perimeter measured 130.2 mm, with a perimeter-derived diameter of 41.4 mm. A 44-mm Evoque valve was selected, with diastolic and systolic oversizing of 6.3% and 12.2%, respectively. Because of the leaflet morphology and IVC obstruction (Figure 3), the patient was not a candidate for tricuspid edge-to-edge repair or transfemoral TTVR. She was inoperable for isolated tricuspid valve surgery. Therefore, a TJ approach was selected. The procedure was performed using the step-by-step procedural guide, with successful deployment of a 44 mm Evqoue valve. Final TR was reduced to a trace paravalvular leak (Supplemental Figure 2). The mean transvalvular gradient was 1 mm Hg, with no evidence of heart block postprocedure. The patient was successfully extubated on the table. Procedure time was 65 minutes. Postprocedure TTE demonstrated a well-positioned valve without regurgitation. The patient was discharged after 2 days with no periprocedural complications or conduction abnormalities.

Figure 3.

CT Images of Adams-DeWesse IVC Clip in Patient 1

Multiplanar CT imaging demonstrating the anatomical constraint that necessitated TJ access for TTVR. (A) Adams DeWeese IVC clip showing the characteristic serrated metal design used for caval interruption. (B) Three-dimensional volume-rendered CT reconstruction illustrating the IVC clip location (yellow outline) within the infrarenal IVC, with multiple cross-sectional measurements showing severe luminal narrowing at various levels (measurements shown in millimeters). The clip created significant stenosis, preventing passage of the 28-F Evoque delivery system. (C) Axial CT image at the level of maximal stenosis showing the residual IVC lumen (blue circle) with quantitative measurements (minimum diameter: 6.8 mm, maximum diameter: 6.9 mm, average diameter: 6.9 mm, cross-sectional area: 37.0 mm², perimeter: 21.6 mm). The dimensions are substantially smaller than the required 28-F (approximately 9.3 mm) delivery system, confirming the anatomical contraindication to TF access. CT = computed tomography; IVC = inferior vena cava; TF = transfemoral; TJ = transjugular; TTVR = transcatheter tricuspid valve replacement.

Case 2

An 84-year-old woman with a history of mitral regurgitation treated with transcatheter edge-to-edge repair presented with symptomatic tricuspid regurgitation despite optimal medical therapy and was deemed inoperable for isolated tricuspid valve surgery. TEE revealed malcoaptation of anterior and septal leaflets leading to symptomatic severe (effective regurgitant orifice area: 0.43 cm²) atrial secondary central tricuspid regurgitation (Supplemental Figure 3). Preprocedural cardiac CT revealed an RA systolic height of 76.2 mm and a diastolic perimeter of 158.4 mm, with a perimeter-derived diameter of 40.4 mm. IVC-to-TVA offset distance was 9.3 mm. Based on these measurements, a 56-mm Evoque valve was selected with systolic and diastolic TVA oversizing of 19.1% and 11.1%, respectively. Initially, a right transfemoral approach was attempted. Unfortunately, the trajectory of the valve delivery system could not be properly aligned for deployment from the right femoral approach. A left femoral attempt was attempted, but significant left iliac vein tortuosity and narrowing prevented advancement of the delivery, even with a stiff Lunderquist “buddy” wire. Given these anatomical limitations, the TF approach was abandoned. The procedure was aborted, and the patient was discharged the following day with a plan to reattempt the procedure via a TJ approach. The patient returned several weeks later for left TJ TTVR. The same procedural steps were followed as mentioned in the step-by-step guide. TEE confirmed a well-seated Evoque valve with elimination of TR. The patient was extubated on the table. The total procedure time was 65 minutes. Postprocedure TTE revealed a well-functioning valve without transvalvular regurgitation (Supplemental Figure 4). She was discharged home on day 2 without complications.

Discussion

Both cases highlight the challenges and procedural adaptations required for Evoque TTVR in patients with anatomical limitations for TF access (Table 1). Insufficient right atrial height (<55-60 mm), which leads to excessive RV implantation depth, is a common cause of TF failure.^3,5 Although switching from right to left femoral access may help, the strategy is not always effective,^3,4,6 as demonstrated in our second patient.

Table 1.

Anatomical Considerations for TTVR via Transjugular Access

Anatomical Consideration	Description	Threshold Value
IVC obstruction	Presence of IVC filter, clip, or occlusion	Any significant narrowing preventing 28-F delivery system
Insufficient RA height	Short RA height in systole	<55-60 mm
Excessive RA heighta	Extremely large RA	>100 mm
IVC-to-TVA offset	Lateral displacement of IVC relative to the tricuspid annulus	Significant offset (>10 mm)
Iliac/Femoral vein tortuosity	Excessive angulation in the venous path	Subjective assessment based on preprocedural CT
RV depth	Distance from tricuspid annulus to RV apex	Case-dependent assessment

CT = computed tomography; IVC = inferior vena cava; RA = right atrium; RV = right ventricle; TVA = tricuspid valve annulus; TTVR = transcatheter tricuspid valve replacement.

^aThere is limited clinical experience with this clinical scenario.

In patient 1, TF access was precluded by an IVC clip causing luminal narrowing <9 mm. In patient 2, both right and left femoral approaches failed because of poor trajectory and iliac vein tortuosity despite imaging suggesting TF feasibility.

In both patients, a TJ route was chosen to overcome these limitations. This decision offered the following distinct advantages:

• 1.Direct coaxial alignment: TJ access provides a more direct and coaxial alignment with the tricuspid annulus with a shorter and less tortuous path to the RA,⁷ potentially reducing the risk of malalignment and facilitating smoother device delivery and deployment.
• 2.Independence from RA height: Access from the internal jugular eliminates the RA height requirements,³ as the implantation depth in the RV can be adjusted by directly manipulating the delivery system, which was particularly important in our first patient with an RA systolic height of only 50.9 mm (ie, below the recommended minimum of 55-60 mm).
• 3.Improved procedural control: The TJ approach provides better control and stability when advancing the delivery system, particularly in navigating the RA-to-RV trajectory.
• 4.Alternative for vascular anomalies: The approach also offers a viable solution for patients with IVC disruption, filters, clips, or significant iliac vein tortuosity.⁴
• 5.Shorter procedural time: In our series, both procedures were completed in 65 minutes—shorter than the average 80-minute procedure time at our institution for TF TTVR.

Key technical considerations for the TJ approach include the following:

• 1.Reversed steering mechanics: The primary flexion knob functionality is reversed compared to the TF approach, requiring operators to adapt their technique⁴ (Figure 2).
• 2.Vascular closure: In both cases, successful hemostasis was achieved using 2 preclosed Perclose sutures coupled with a figure-of-eight stitch, allowing for early ambulation. The optimal approach for TJ vascular closure remains to be established.
• 3.Imaging guidance: Comprehensive multimodality imaging with TEE and, when needed, ICE, remains crucial for successful valve deployment.

Transthoracic echocardiography at 24 hours postprocedure confirmed excellent valve function in both patients, with no transvalvular regurgitation. Importantly, there were no periprocedural complications, conduction disturbances, or new or worsening pericardial effusions, further supporting the safety profile of this approach.

Should Transjugular Access Be Considered as an Upfront Procedure?

Although TF access remains the primary approach for most TTVR procedures, our experience and the growing literature suggest that TJ access should be an upfront strategy in specific patient subsets.^3,6 We propose an algorithm for determining the optimal access route for TTVR with the Evoque system (Figure 4), incorporating key anatomical measurements and clinical considerations to guide decision-making. We recommend considering upfront TJ access in the following scenarios:

• 1.Presence of IVC disruption, filters, or clips
• 2.RA systolic height <55 mm
• 3.RA systolic height >100 mm
• 4.IVC-to-TVA offset >10 mm
• 5.Severe iliac or femoral vein tortuosity identified on preprocedural CT
• 6.Failed previous transfemoral TTVR attempt

Figure 4.

Algorithm for Determining Optimal Access Route for TTVR With Evoque

(Right) Decision-making algorithm for selecting between TF and TJ access routes for TTVR using the Evoque system. The flowchart begins with patient assessment and proceeds through 3 key decision points: 1) IVC obstruction assessment: Patients with IVC clips, filters, occlusion, or significant luminal narrowing should receive primary TJ access; 2) RA height evaluation: Patients with systolic RA height <55 mm or >100 mm∗ (∗limited clinical experience using TJ for this clinical scenario) should be considered for TJ access owing to suboptimal working room; and 3) assessment of IVC-to-TVA offset and venous anatomy: Patients with significant offset (>10 mm) or severe iliac/femoral vein tortuosity should be considered for TJ access. Patients without these anatomical constraints are candidates for primary TF access, with the option to convert to TJ access if procedural challenges arise during this approach. (Left) Key procedural considerations specific to the TJ approach, including reversed delivery system mechanics, specific closure techniques, room setup optimization, enhanced imaging requirements, and the ability to directly manipulate RV implantation depth. IVC = inferior vena cava; RA = right atrium; RV = right ventricle; TF = transfemoral; TJ = transjugular; TR = tricuspid regurgitation; TTVR = transcatheter tricuspid valve replacement; TVA = tricuspid valve annulus.

For patients without these specific features, TF access remains appropriate as the first-line approach. However, operators should maintain a low threshold for switching to TJ access when challenges arise. Operators must be aware of the different delivery system techniques (Figure 2) and procedural setup (Figure 1) to accommodate the alternative workflow. Moreover, the direct, coaxial route of the TJ approach leading to a faster valve deployment also reinforces the value of considering TJ access for procedural streamlining.

Conclusions

Given the evolving landscape of transcatheter tricuspid therapies, our experience and step-by-step guide add to the growing body of evidence supporting the use of a TJ approach in patients with challenging anatomy, vascular limitations, or failed transfemoral deployment attempts. Upfront consideration of a TJ approach may be considered in the presence of specific anatomical criteria, such as IVC obstruction, RA systolic height <55 to 60 mm, excessive RA height >100 mm, significant iliac vein tortuosity, and large IVC-to-TVA offset. Future studies are needed to define optimal patient selection criteria, long-term valve durability, and comparative outcomes between TF and alternative access approaches. As centers gain experience with the Evoque system, protocol-driven algorithms for access route selection will help optimize procedural planning and outcomes.

Funding Support and Author Disclosures

Dr Depta has been a consultant and/or member of the advisory board for Edwards Lifesciences and Boston Scientific. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Appendix

Video 1

TEE Showing Quadricuspid Valve With Flail Posterior Leaflet

Supplemental Figures

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