A Novel Commissural Symmetrical Closure Strategy for Transcatheter Tricuspid Annuloplasty Enabling Maximized Annular Reduction

Background Refractory functional tricuspid regurgitation (TR) secondary to annular dilatation portends poor prognosis, although conventional open tricuspid surgery carries high-risk in elderly patients. The optimal K-Clip deployment geometry for maximal annular reduction remains undefined.Case summary An 89-year-old pacemaker-dependent man with decompensated right heart failure and refractory functional TR was prohibitively high-risk for open surgery. Preoperative imaging identified anatomy less favorable for transcatheter edge-to-edge tricuspid repair. K-Clips were implanted perpendicularly to tricuspid commissures via the commissural symmetrical closure (CSC) strategy, yielding significant annular reduction. Three-month follow-up showed sustained TR improvement and stable clip positioning.Discussion Perpendicular orientation geometrically maximizes annular plication, enabling optimal annular contraction and TR relief. Dual fluoroscopic and live 3D transesophageal echocardiographic guidance ensures safe and precise deployment.Take-home message The commissural symmetrical closure strategy optimizes K-Clip geometric alignment to maximize tricuspid annular reduction and ameliorate severe functional TR, offering a safe and feasible transcatheter annuloplasty approach for high-risk elderly patients.