When Left Is Right: Multimodality Insights Into How Left Internal Jugular Access Optimizes Device Trajectory and Geometry in Transcatheter Tricuspid Valve Replacement

Abstract Background Edwards EVOQUE system is a transcatheter tricuspid valve replacement (TTVR) option designed for right transfemoral access, however, suboptimal valve positioning and delivery occurs in patients with unfavorable anatomy. When considering alternative access, early uses of left internal jugular (LIJ) access has seen procedural success and hosts advantageous mechanisms that are poorly understood. Aims To understand the mechanism of LIJ approach by developing a mechanistic framework that demonstrates the geometric advantages compared to right internal jugular (RIJ) and how it can improve EVOQUE valve positioning and delivery Methods and results Retrospective analysis of 24 patients (LIJ = 13, RIJ = 11) who underwent successful TTVR procedure between June 2024 and September 2025. Multimodality analysis combining echocardiography, cardiac computed tomography and fluoroscopy was performed to analyze delivery system positions LIJ demonstrated larger delivery system distance to septal wall (16.6 ± 5.3 mm) than RIJ (9.5 ± 3.5 mm)(P < 0.001) and was similarly observed at 10 mm and 20 mm proximal points, across 3 time points as validated by transesophageal echocardiography septal distances to delivery system. Trajectory of delivery system averaged LIJ = 17.8 ± 4.8° vs RIJ = 2.3 ± 2.8° (P < 0.010). LIJ primary flexion angle on average was larger at 82.0 ± 14.1° vs 57.2 ± 21.8°, P = 0.003. CT 3D modeling estimated larger average distance of delivery system to septal plane for LIJ (24.4 ± 9.1 mm vs 19.3 ± 7.3 mm) and length of primary flexion to tricuspid annulus (52.4 ± 8.0 mm vs 44.4 ± 5.7mm, P < 0.05). Conclusions In this single-centre experience, LIJ access facilitated more central placement of EVOQUE delivery system in the septal-lateral tricuspid annular plane and improved trajectory alignment in TTVR with EVOQUE which correlated with comparable procedure times and safety compared to other access choices. While these findings offer a mechanistic rationale for LIJ access in selected patients, larger prospective multi-centre studies are required to confirm clinical superiority and refine patient selection criteria.