Pre-implantation planning is based on clinical, hemodynamic and anatomical features. The system is designed for patients with at least severe TR. In summary, the TricValve^® studies only included patients severely symptomatic (NYHA functional class III or IV or with previous admission for heart failure during last 12 months) despite optimal medical therapy, and deemed at high or prohibitive surgical risk for conventional tricuspid surgery. Pacemaker leads were not a contraindication. However, those with severe pulmonary hypertension (systolic pulmonary pressure >65 mmHg) or severe impaired right ventricular function (i.e., TAPSE < 13 mm) were contraindications. TricValve^® requires a significant tricuspid V-wave to ensure adequate valve leaflet motion. Usually, a tricuspid V-wave is large in patients with severe TR. However, the tricuspid V-wave can be low in some circumstances even with severe TR, particularly if the RA is very large, or if right ventricular function is depressed, particularly when the intravascular volume is depleted. Tricvalve^® should not be recommended if v-waves are <15 mmHg measured during a euvolumic setting.

Anatomically, bioprosthesis sizing requires accurate caval measurements on CT scanning to minimize the possibility of any safety issues and suboptimal performance results. Contrast-enhanced CT of the chest and abdomen, performed 70 to 85 s after injecting contrast agent into a peripheral vein is recommended for an uniform enhancement of both, SVC and IVC. An oversizing degree of 10 to 40% within the belly part for the SVC prosthesis and in the proximal part of the IVC prosthesis is desirable for optimizing fixation and seal. For the SVC, critical references are the diameter at the level of the confluence with the innominate trunk, the diameter at the level of pulmonary artery, diameter at the cavo-atrial junction, and the distance between these points. A minimum length of 50 mm between cavo-atrial junction and innominate confluence is needed for the SVC. The target position is to place the belly part of the SVC prosthesis, which has a long skirt covering the inferior half of the belly, at the level where the right pulmonary artery crosses the SVC. There should be caution in patients with short and tapered SVC, because risk of migration is higher in such anatomies. In these instances, a higher implant technique is recommended by placing the belly part of the SVC prosthesis between the confluence and the right pulmonary artery level. However, the belly part should not be positioned at the level of the confluence because of the risk of innominate occlusion. A high implantation technique is also recommended in patients with pacemaker or implantable cardioverter-defibrillator leads for minimizing the risk of migration.

For the IVC prosthesis, the critical points are diameters at the level of the junction with RA, below and above the hepatic veins, and the distance between supra-hepatic veins and cavo-atrial junction. Target position is to implant the proximal edge between the junction and the confluence of the supra-hepatic veins, entering into the atrium between 5 to 12 mm depending on the anatomy. The risk of peri-valvular leak increases if the proximal edge of the device enters within into the atrium more than 15 mm, since only the first 20 proximal mm of the device are covered by the skirt. Special caution is required in patients with a short distance between the supra-hepatic veins and the cavo-atrial junction, in patients with significant differences in diameter above and below the hepatic veins, or in patients with significant angulations between the cavo-atrial junction. In these cases, the contact between the device and the caval wall is less and this could affect device stability. To increase the attachment area, the valve should be positioned as low as possible (entering only 0–5 mm into the atrium). A very slow deployment is also recommended.

The implantation requires 3 access sites (option of 4th): 1 right common femoral vein (27.5F) for device deployment and 2 left common femoral vein (5F and 7F) for pigtail control injections and a Swan-Ganz catheter. Optionally a 4th left basilic vein access (5F) can be useful for better identifying the confluence between innominate and SVC. Pre-closure with 1–2 Proglides in the right common femoral vein can be useful for hemostasis, but not mandatory. A Swan-Ganz catheter should be placed at the level of right pulmonary artery for reference. Using the pigtail (+ a multipurpose catheter within the innominate vein), an angiogram of the SVC with special attention to the confluence and the distance between the innominate vein ostium and the SVC at the level where the right branch of the pulmonary artery crosses it is recommended for planning the deployment (Figure 2A,B). A stiff wire placed in the subclavian or internal jugular vein is recommended for valve deployment. There are usually venous valves at the entrance to the subclavian or jugular vein. Careful handling with a multipurpose catheter may be necessary to cross these valves, often via simple catheter rotation as opposed to pushing. Deployment is undertaken by rotating the device’s roulette clockwise. Deployment should be performed slowly, starting in a high position and pulling down the system until it arrives at the target position (Figure 2C). It is not recommended to push the device for avoiding a venous wall pinching. The system is retrievable until the 80% is deployed. If we need to implant the device in a higher position we should re-sheath the system completely and re-start again in a higher position. Being a self-expanding device with a lot of radial force, the device trends to come out of the delivery system, so in general it is necessary to maintain tension during the deployment. Once the belly part of the prosthesis is deployed the systems remains very stable and we can release the tension. It is important to be sure that all 3 hooks attached to the device are released. Before removing the delivery system out of the patient, one should re-sheath it completely to avoid vascular complications.

For the IVC deployment, a venogram of the hepatic veins centered in the confluence with inferior cava and its junction with the RA is obtained, and serves as a reference for deployment (Figure 2D). The IVC prosthesis is deployed in a similar way to the SVC prosthesis, starting in a high position, into the right atrium, and pulling down the system at the same time that we are deploying the valve until our target position (proximal edge of the prosthesis landing in between the right atrium and supra-hepatic vein confluence) (Figure 2E). Depending on the anatomy or prosthesis size, a low implantation is typically recommended (as explained above). A TEE or transthoracic echocardiography can be useful, as the entrance or junction between IVC and right atrium is usually very well defined in the bi-caval view or sub-costal view. If echocardiographic images are available, a measure of the mm of the valve entering into the RA can be obtained during the deployment, as well as the presence of any leak (Figure 2F). The system is retrievable until 80% of the prosthesis is deployed. At this point the system remains very stable, then a release of tension is recommended for avoiding a jump effect when the knocks are untied. It is important to confirm that all 3 hooks attached to the device are released. The delivery system must be fully re-sheathed before removing it in order to avoid vascular complications.