Use of inhaled nitric oxide in facilitating tricuspid TEER: A novel approach

Patients with torrential tricuspid regurgitation (TR) and large leaflet gaps pose technical challenges for tricuspid valve transcatheter edge-to-edge repair (t-TEER). We report the novel use of inhaled nitric oxide (iNO) as a hemodynamic adjunct in t-TEER in a 59-year-old female with torrential TR and NYHA Class IV heart failure. After an unsuccessful initial TEER attempt with the TriClip device due to a large leaflet gap, iNO was initiated at the repeat t-TEER attempt for the intraoperative reduction of pulmonary vascular resistance (PVR) and right ventricle (RV) afterload. This decreased intraoperative TR severity and optimized valve geometry for easier leaflet grasping, allowing for successful deployment of two TriClips. • Intraoperative inhaled nitric oxide (iNO) optimizes tricuspid valve geometry and facilitates leaflet grasping during t-TEER. • iNO administration acutely reduced pulmonary vascular resistance and RV afterload, enabling successful TriClip deployment. • This case demonstrates a novel hemodynamic strategy to overcome anatomical barriers in transcatheter tricuspid interventions.