Electrosurgical laceration and stabilisation of tricuspid edge-to-edge repair: the ELASTA-T technique

Abstract

Recurrent tricuspid valve regurgitation (TVR) after tricuspid transcatheter edge-to-edge repair (T-TEER) poses a significant challenge, particularly when centrally positioned clips impede subsequent transcatheter tricuspid valve replacement (TTVR). Electrosurgical laceration and stabilisation of T-TEER (ELASTA-T) has been developed to facilitate TTVR by enabling controlled single leaflet device attachment (SLDA). The aim of this manuscript is to provide a step-by-step standardised description of the ELASTA-T strategy, outlining essential procedural principles, the required equipment, and technical steps. ELASTA-T involves intentional detachment of the most centrally placed tricuspid clip using electrosurgical leaflet laceration. A modified coronary guidewire shaped into a “flying V” – based on Bioprosthetic Aortic Scallop Intentional Laceration to prevent Iatrogenic Coronary Artery obstruction (BASILICA) and Laceration of the Anterior Mitral leaflet to Prevent Outflow ObstructioN (LAMPOON) principles – is positioned across the target leaflet using bilateral femoral vein access, deflectable guiding sheaths, microcatheters, and a snare-assisted venovenous rail. Laceration is performed under fluoroscopic and transoesophageal echocardiographic guidance, with preventive haemodynamic support on standby because of the risk of transient severe TVR. After laceration, the clip is mobilised towards the septal leaflet to avoid interference with valve deployment, followed by immediate implantation of a dedicated transcatheter tricuspid valve (TTV). ELASTA-T allows safe and reproducible SLDA, creating adequate central space for accurate positioning and full expansion of a TTV. Detachment can be reliably confirmed by fluoroscopy and transoesophageal echocardiography. By removing any mechanical obstruction from centrally placed clips, the technique facilitates secure TTVR anchoring and may reduce paravalvular regurgitation. This step-by-step framework may support procedural standardisation and broader adoption, ultimately improving outcomes in this high-risk population.