BACKGROUND:Reduction of mitral regurgitation (MR) in mitral transcatheter edge-to-edge repair (M-TEER) improves patient outcomes and is balanced against elevated mitral valve gradients (MVGs). OBJECTIVES:This study sought to evaluate impact of residual MR and MVG on echocardiographic and clinical outcomes post-M-TEER. METHODS:One-year outcomes from the randomized CLASP IID (Edwards PASCAL TrAnScatheter Valve RePair System Pivotal Clinical Trial) were analyzed by discharge MR and MVG. RESULTS:Of the 284 patients with available discharge echocardiogram, 72.5% (n = 206) achieved an optimal result (MR ≤1+ and MVG ≤5 mm Hg) and 27.5% (n = 78) achieved a suboptimal result (MR ≤1+ and MVG >5 mm Hg, MR ≥2+ and MVG ≤5 mm Hg, or MR ≥2+ and MVG >5 mm Hg). Optimal result patients had significantly improved pulmonary vein flow and tricuspid annular plane systolic excursion and experienced significantly higher freedom from major adverse events (MAEs) (89.5% vs 79.7%; P = 0.023), mortality (94.1% vs 85.4%; P = 0.016), and the composite of mortality, heart failure hospitalization, or reintervention (88.6% vs 78.7%; P = 0.022) at 1 year. Within suboptimal result patients, freedom from clinical events was higher with MR ≤1+ and MVG >5 mm Hg compared with MR ≥2+ and MVG ≤5 mm Hg at 1 year (MAEs: 87.7% vs 75.5%; mortality: 90.9% vs 84.6%; composite: 87.9% vs 72.5%). CONCLUSIONS:In the CLASP IID trial, an optimal result was associated with improved hemodynamics with significantly higher freedom from MAEs, all-cause mortality, and composite events at 1 year. Within a suboptimal result, achieving MR ≤1+ and MVG >5 mm Hg demonstrated better 1-year prognosis compared with achieving MR ≥2+ and MVG ≤5 mm Hg, suggesting a clinical benefit of optimizing MR over preserving lower gradients. (Edwards PASCAL TrAnScatheter Valve RePair System Pivotal Clinical Trial [CLASP IID]; NCT03706833).

BACKGROUND AND AIMS:The TRISCEND II trial demonstrated superior clinical benefits for patients with ≥severe tricuspid regurgitation (TR) treated with the EVOQUE transcatheter tricuspid valve replacement (TTVR) system plus medical therapy vs medical therapy alone. This work reports 1-year and 18-month outcomes in patients stratified by baseline TR severity. METHODS:The multicentre, prospective TRISCEND II trial enrolled 400 patients with symptomatic, ≥severe TR, and randomized 2:1 to TTVR (n = 267) or control (n = 133). In a post hoc analysis, patients were stratified into severe TR (n = 172) and massive/torrential TR (n = 220) cohorts. Clinical and quality-of-life outcomes were reported at 1 year, with Kaplan-Meier estimates for all-cause mortality and heart failure (HF) hospitalization assessed at 18 months. Study oversight included an independent echocardiographic core laboratory, clinical events committee, and data safety monitoring board. RESULTS:One year after TTVR, TR was ≤mild in 95.2% of severe TR and 95.3% of massive/torrential TR patients. The primary safety and effectiveness endpoint (win ratio) favoured TTVR over control regardless of baseline TR severity: severe {1.64 [95% confidence interval (CI): 1.11, 2.43]} and massive/torrential [2.20 (1.55, 3.14)]. At 18 months, TTVR patients had similar mortality to controls [rate difference: severe 0.2% (-11.6, 11.9), massive/torrential -5.8% (-17.6, 6.0)], whereas HF hospitalization rates favoured TTVR in the massive/torrential cohort [vs control, severe 9.8% (-3.0, 22.7), massive/torrential -15.2% (-28.9, -1.5)]. CONCLUSIONS:Patients with ≥severe TR benefit from TTVR, experiencing improvements in TR severity, functional capacity, and quality of life regardless of baseline TR severity, with a signal for greater benefit in patients with more advanced disease.

BACKGROUND:Patients undergoing orthotopic transcatheter tricuspid valve replacement (TTVR) frequently present with a cardiac implantable electronic device (CIED) lead traversing the tricuspid valve. OBJECTIVES:This study sought to investigate the clinical, procedural, and lead-related outcomes of orthotopic TTVR in patients with transvalvular CIED leads. METHODS:All consecutive patients enrolled in the multicenter TRIPLACE (Global Multicenter Registry on Transcatheter Tricuspid Valve Replacement) registry were included for analysis. Patients were stratified based on the presence of a CIED lead traversing the tricuspid valve. Changes in lead function parameters were assessed after TTVR in a subset of these patients who had pacemaker lead parameter data recorded. Lead failure was defined as structural or electrical malfunction requiring new lead or CIED insertion. RESULTS:Among 395 patients, 104 (26.3%) had transvalvular CIED leads. Procedural success, symptomatic improvement, and 30-day mortality were comparable between those with and without CIED. Patients with CIED leads had lower rates of mild or less residual tricuspid regurgitation (82.6% vs 91.4%; P < 0.041) and higher rates of moderate or greater paravalvular leak (17.1% vs 7.1%; P < 0.017). Lead failure occurred in 5.8% over a median follow-up time of 183 days, with modest changes in pacing thresholds. No significant increase in adverse events or mortality was observed at 30 days. CONCLUSIONS:Orthotopic TTVR in patients with transvalvular CIED leads can be safely and effectively performed with low rates of lead failure. Significant paravalvular leak and residual tricuspid regurgitation is more common with a jailed lead. These patients require close CIED follow-up with alternative pacing strategies in place, particularly when pacing dependent. (Global Multicenter Registry on Transcatheter TRIcuspid Valve RePLACEment [TRIPLACE]; NCT06033274).

Background The clinical efficacy of transcatheter tricuspid valve replacement (TTVR) in abolishing tricuspid regurgitation might be attenuated by the occurrence of paravalvular leak (PVL). Objectives The aim of this study was to investigate the incidence, outcomes, and predictors of moderate or severe PVL post-TTVR. Methods All eligible patients undergoing TTVR in the multicenter TRIPLACE (Global Multicenter Registry on Transcatheter Tricuspid Valve Replacement) registry were stratified according to predischarge PVL severity. The primary endpoint was the occurrence of moderate or severe PVL post-TTVR. Secondary endpoints were 1-year mortality, 1-year heart failure hospitalization, and post-TTVR NYHA functional class III or IV. Outcomes were analyzed using logistic regression (PVL), Cox regression (mortality), and Gray’s test (heart failure). Results Of 394 TTVR patients, 24 (6.1%) had moderate or severe, 88 (22.3%) mild, and 282 (71.6%) no or trace PVL post-TTVR. Patients with moderate or severe PVL had significantly higher TRI-SCOREs (P < 0.001), lower estimated glomerular filtration rates (P = 0.001), and larger right ventricular and right atrial dimensions (P = 0.002 for both). Patients with moderate or severe PVL post-TTVR had worse 1-month functional class (53% in NYHA functional class III or IV) than those with mild (16%) or no or trace (15%) PVL. The presence of moderate or severe PVL post-TTVR was associated with increased 1-year mortality (39.7%; adjusted HR: 2.6; 95% CI: 1.2-5.7) compared with those with mild (12.6%) or no or trace (10.5%) PVL. A larger right atrial volume (P = 0.02), device malposition (P = 0.0002), and type IV valve morphology (P = 0.01) were independently associated with moderate or severe PVL post-TTVR. Conclusions Moderate or greater PVL occurred in 6.1% of patients post-TTVR and was associated with increased 1-year mortality and worse functional status. A larger right atrial volume, device malposition, and type IV valve morphology conferred a higher risk for developing moderate or severe PVL post-TTVR. These findings have important implications for future TTVR design and procedural optimization. (Global Multicenter Registry on Transcatheter Tricuspid Valve Replacement [TRIPLACE]; NCT06033274)

BACKGROUND:The TRISCEND II (EVOQUE Transcatheter Tricuspid Valve Replacement: Pivotal Clinical Investigation of Safety and Clinical Efficacy Using a Novel Device) trial demonstrated clinical benefits for transcatheter tricuspid valve replacement (TTVR) with the EVOQUE System over medical therapy for the primary safety and effectiveness endpoint to 1 year. OBJECTIVES:The authors report echocardiographic outcomes at 1 year for the randomized cohort and evaluate hemodynamic and structural changes. METHODS:The multicenter, prospective TRISCEND II trial enrolled 400 patients with severe, symptomatic tricuspid regurgitation (TR) and randomized them in a 2:1 ratio to TTVR (n = 267) or medical therapy (control) (n = 133). The secondary echocardiographic endpoint was reduction in TR severity from baseline to discharge. Echocardiograms were evaluated by an independent echocardiographic core laboratory. RESULTS:All patients had severe TR at baseline; at discharge, 95.5% of patients who underwent TTVR had mild TR. On paired analysis from baseline to 1 year, 95.3% of patients who underwent TTVR and 2.3% of control patients achieved mild TR. Between baseline and 1 year, the mean inferior vena cava diameter decreased significantly more for patients who underwent TTVR (normal breathing P < 0.001; forced inhalation P = 0.038). Patients who underwent TTVR experienced greater improvements in diastolic right ventricular (RV) size (P < 0.05) and larger decreases in RV systolic function (P < 0.001), consistent with reduced preload from TR reduction. RV stroke volume and cardiac output increased significantly in patients who underwent TTVR (P < 0.001) but not in control patients. CONCLUSIONS:One-year echocardiographic outcomes from the TRISCEND II trial demonstrated that near elimination of TR following TTVR is associated with reduced venous congestion, RV reverse remodeling, and significant improvements in forward stroke volume and cardiac output. (EVOQUE Transcatheter Tricuspid Valve Replacement: Pivotal Clinical Investigation of Safety and Clinical Efficacy Using a Novel Device [TRISCEND II Pivotal Trial]; NCT04482062).

The first Tricuspid Valve Academic Research Consortium publication standardized definitions of disease etiology and severity, as well as standardized endpoints for trials to address the knowledge gaps related to identification and management of patients with tricuspid regurgitation. Based on randomized trials comparing transcatheter tricuspid valve intervention with optimal medical therapy, transcatheter edge-to-edge repair and tricuspid valve replacement were approved by the U.S. Food and Drug Administration and received CE Mark. These technologies represent a major step forward for patients with severe symptomatic tricuspid regurgitation and transcatheter tricuspid valve intervention. This second chapter of the Tricuspid Valve Academic Research Consortium focuses on defining specific trial design and endpoint options for comparisons of emerging technologies, tricuspid valve surgery, and medical therapy.

BACKGROUND:Transcatheter mitral valve replacement (TMVR) may benefit patients at high surgical risk with mitral regurgitation (MR). OBJECTIVES:The authors report 30-day and 1-year outcomes of transfemoral TMVR. METHODS:The MISCEND (Edwards Eos Mitral Valve Replacement: Investigation of Safety and Performance After Mitral Valve Replacement With Transcatheter Device) study is a prospective, single-arm, multicenter evaluation of the Eos transcatheter mitral valve replacement system for clinically significant, symptomatic MR. Performance and safety endpoints included device success, procedural success, 30-day rate of MR ≤1+ and 30-day composite major adverse event rate. Additional clinical, echocardiographic, functional, and quality-of-life outcomes were assessed through 1 year. RESULTS:Sixty patients (median age 79.5 years, Society of Thoracic Surgeons score 5.2%, 40% men, 43.3% with functional MR) were enrolled. Device and procedural success rates were 100.0%. The 30-day composite major adverse event rate was 43.3%, including all-cause mortality (5.0%), all-cause hospitalization (21.7%), nonelective mitral valve reintervention (1.7%), severe bleeding (28.3%), renal complication requiring unplanned dialysis or renal replacement therapy (5.0%), and major cardiac structural complication (8.3%). The rate of MR ≤1+ was 98.1% at 30 days and 100.0% at 1 year, with none/trace MR in 63.0% and 78.4% of patients, respectively. One-year outcomes showed significant improvements in 6-minute walk distance (40.5 m; 95% CI: 13.8-97.2 m; P = 0.003) and Kansas City Cardiomyopathy Questionnaire overall score (17.7 points; 95% CI: 11.2-27.3 points; P < 0.01), with 86.8% of patients in NYHA functional class I/II. Rates of mortality and left ventricular pseudoaneurysm were 20.3% and 10.0%, respectively. CONCLUSIONS:1-year MISCEND results demonstrate the feasibility of TMVR with the Eos system. Although safety concerns related to left ventricular pseudoaneurysm resulted in the cessation of study enrollment, learnings will inform future therapy development.

BACKGROUND Severe tricuspid regurgitation is associated with disabling symptoms and an increased risk of death. Data regarding outcomes after percutaneous transcatheter tricuspid-valve replacement are needed. METHODS In this international, multicenter trial, we randomly assigned 400 patients with severe symptomatic tricuspid regurgitation in a 2:1 ratio to undergo either transcatheter tricuspid-valve replacement and medical therapy (valve-replacement group) or medical therapy alone (control group). The hierarchical composite primary outcome was death from any cause, implantation of a right ventricular assist device or heart transplantation, postindex tricuspid-valve intervention, hospitalization for heart failure, an improvement of at least 10 points in the score on the Kansas City Cardiomyopathy Questionnaire overall summary (KCCQ-OS), an improvement of at least one New York Heart Association (NYHA) functional class, and an improvement of at least 30 m on the 6-minute walk distance. A win ratio was calculated for the primary outcome by comparing all possible patient pairs, starting with the first event in the hierarchy. RESULTS A total of 267 patients were assigned to the valve-replacement group and 133 to the control group. At 1 year, the win ratio favoring valve replacement was 2.02 (95% confidence interval [CI], 1.56 to 2.62; P<0.001). In comparisons of patient pairs, those in the valve-replacement group had more wins than the control group with respect to death from any cause (14.8% vs. 12.5%), postindex tricuspid-valve intervention (3.2% vs. 0.6%), and improvement in the KCCQ-OS score (23.1% vs. 6.0%), NYHA class (10.2% vs. 0.8%), and 6-minute walk distance (1.1% vs. 0.9%). The valve-replacement group had fewer wins than the control group with respect to the annualized rate of hospitalization for heart failure (9.7% vs. 10.0%). Severe bleeding occurred in 15.4% of the valve-replacement group and in 5.3% of the control group (P=0.003); new permanent pacemakers were implanted in 17.4% and 2.3%, respectively (P<0.001). CONCLUSIONS For patients with severe tricuspid regurgitation, transcatheter tricuspid-valve replacement was superior to medical therapy alone for the primary composite outcome, driven primarily by improvements in symptoms and quality of life.

As transcatheter tricuspid valve replacement with the EVOQUE system gains wider clinical adoption, growing experience has highlighted key anatomical considerations that influence procedural success. While right transfemoral (TF) access is the standard approach, it can be technically challenging in patients with complex right heart anatomy, such as low right atrium (RA) height or a large inferior vena cava-tricuspid valve annulus (IVC-TVA) offset. These factors may lead to suboptimal trajectory, impaired coaxiality, and difficult valve deployment. Left TF access offers a potential alternative by providing additional RA height and a more favorable lateral trajectory, allowing improved alignment with the tricuspid valve annulus (TVA). This approach is particularly useful in patients with large short-axis (SAX) offsets (>20 mm) or steep long-axis angles where right TF access may not achieve perpendicular orientation despite secondary catheter flexion. Using a preprocedural cardiac computed tomography angiography (CCTA) scan, anatomical factors such as RAH, leaflet tethering height, RV depth, and papillary muscle location can be evaluated to guide access planning. While left TF access introduces its own technical considerations, including venous tortuosity, excessive unwanted RA height, and increased need for primary flex, it may expand procedural feasibility in anatomically challenging cases. This review outlines real-world scenarios where left-sided access was favored, supporting its use as a safe and effective strategy in selected patients. Further studies are warranted to assess long-term outcomes and to inform the design of next-generation delivery systems capable of accommodating broader anatomical variation.

BACKGROUND:One-year outcomes from the CLASP IID Trial (Edwards PASCAL TrAnScatheter Valve RePair System Pivotal Clinical Trial; NCT03706833) and Registry established the PASCAL transcatheter valve repair system as a safe and effective treatment for prohibitive-risk degenerative mitral regurgitation (DMR). Longer-term follow-up is ongoing. OBJECTIVES:This paper reports the CLASP IID Trial and Registry 2-year outcomes. METHODS:In the CLASP IID Trial, prohibitive-risk patients with 3+/4+ DMR, deemed suitable for both the PASCAL and MitraClip systems, were randomized 2:1 (PASCAL: n = 204; MitraClip: n = 96). Patients with complex anatomy deemed ineligible for randomization were enrolled in the CLASP IID Registry (N = 98) and treated with the PASCAL system. RESULTS:In the randomized cohort, significant and sustained MR reduction was achieved at 2 years. MR ≤2+ rate was 95.0% (96/101) in the PASCAL group vs 91.5% (54/59) in the MitraClip group (P = 0.500), and MR ≤1+ rate was 77.2% (78/101) vs 67.8% (40/59) (P = 0.198), respectively. Kaplan-Meier estimates for freedom from all-cause mortality, cardiovascular mortality, heart failure hospitalization, and nonelective mitral valve reinterventions were 80.8% vs 86.2% (P = 0.216), 88.6% vs 90.4% (P = 0.666), 86.4% vs 94.3% (P = 0.058), and 97.9% vs 97.9% (P = 0.962), respectively. In the registry cohort, 91.9% (34/37) achieved MR ≤2+ and 64.9% (24/37) achieved MR ≤1+. Kaplan-Meier estimates for freedom from all-cause mortality, cardiovascular mortality, heart failure hospitalization, and nonelective mitral valve reinterventions were 77.2%, 84.0%, 85.1%, and 99.0%, respectively. Significant improvements in functional status and quality of life were observed in both cohorts. CONCLUSIONS:Two-year outcomes from the CLASP IID Trial and Registry show favorable survival, and significant and sustained MR reduction with functional and quality-of-life improvements, confirming sustained safety and effectiveness of the PASCAL system in treating a broad population of DMR patients.

Background: Severe tricuspid regurgitation (TR) often causes substantial impairment in patient-reported health status (ie, symptoms, physical and social function, and quality of life), which may improve with transcatheter tricuspid valve replacement (TTVR). Objectives: The authors performed an in-depth analysis of health status of patients enrolled in the TRISCEND (Edwards EVOQUE Transcatheter Tricuspid Valve Replacement: Pivotal Clinical Investigation of Safety and Clinical Efficacy using a Novel Device) II pivotal trial to help quantify the benefit of intervention to patients. Methods: The TRISCEND II pivotal trial randomized 400 patients with symptomatic and severe or greater TR 2:1 to TTVR with the EVOQUE tricuspid valve replacement system plus optimal medical therapy (OMT) or OMT alone. Health status was assessed with the Kansas City Cardiomyopathy Questionnaire and the 36-Item Short Form Health Survey. Changes in health status over 1 year were compared between treatment groups using mixed-effects repeated-measures models. Results: The analysis cohort included 392 patients, of whom 259 underwent attempted TTVR and 133 received OMT alone (mean age 79.2 +/- 7.6 years, 75.5% women, 56.1% with massive or torrential TR). Patients had substantially impaired health status at baseline (mean Kansas City Cardiomyopathy Questionnaire Overall Summary Score [KCCQ-OS] 52.1 +/- 22.8; mean 36-Item Short Form Health Survey physical component summary score 35.2 +/- 8.4). TTVR+OMT patients reported significantly greater improvement in both disease-specific and generic health status at each follow-up time point. Mean between-group differences in the KCCQ-OS favored TTVR+OMT at each time point: 11.8 points (95% CI: 7.4-16.3 points) at 30 days, 20.8 points (95% CI: 16.1-25.5 points) at 6 months, and 17.8 points (95% CI: 13.0-22.5 points) at 1 year. In subgroup analyses, TTVR+OMT improved health status to a greater extent among patients with torrential or massive TR vs severe TR (treatment effect 23.3 vs 22.6 vs 11.3; interaction P = 0.049). At 1 year, 64.6% of TTVR+OMT patients were alive and well (KCCQ-OS >= 60 points and no decline of >= 10 points from baseline) compared with 31.0% with OMT alone. Conclusions: Compared with OMT alone, treatment of patients with symptomatic and severe or greater TR with TTVR+OMT resulted in substantial improvement in patients' symptoms, function, and quality of life. These benefits were evident 30 days after TTVR, continued to increase through 6 months, and remained durable through 1 year.

BACKGROUND:The impact of extramitral cardiac damage (EMCD) in patients undergoing mitral valve transcatheter edge-to-edge repair (M-TEER) for degenerative mitral regurgitation (DMR) is unknown. OBJECTIVES:The aim of this study was to understand M-TEER outcomes stratified by the extent of EMCD. METHODS:One-year outcomes from the randomized CLASP IID (Edwards PASCAL Transcatheter Valve Repair System Pivotal Clinical Trial) trial (NCT03706833) in prohibitive surgical risk patients with 3+ or 4+ DMR were analyzed by baseline EMCD stages (stage 0, no EMCD; stage 1, left ventricular remodeling; stage 2, left atrial remodeling; stage 3, pulmonary hypertension and/or tricuspid regurgitation; stage 4, right ventricular dysfunction). RESULTS:The analysis included 211 patients: 53.1% in stages 0, 1, and 2 (n = 112), 13.3% in stage 3 (n = 28), and 33.6% in stage 4 (n = 71). Stages 0, 1, and 2 were combined because there were few patients in stage 0 (n = 3) and stage 1 (n = 1). At baseline, patients with more advanced cardiac damage had more comorbidities, lower functional and quality-of-life measures, and greater mitral regurgitation severity. One-year rates of clinical events among all stages were comparable for major adverse events (P = 0.343) and all-cause mortality (P = 0.644) and significantly different for heart failure hospitalization (P = 0.012). Patients in all stages achieved comparable echocardiographic and quality-of-life improvements at 1 year, including mitral regurgitation ≤1+ (P = 0.474), left ventricular diastolic (P = 0.619) and systolic (P = 0.676) volumes, and Kansas City Cardiomyopathy Questionnaire score (P = 0.335), with significant improvements from baseline (P < 0.05 vs baseline for all). CONCLUSIONS:Results from the CLASP IID trial demonstrate benefit of M-TEER in DMR patients across all EMCD stages, including stage 4, with low major adverse events and all-cause mortality and comparable significant improvements in echocardiographic and quality-of-life outcomes at 1 year.

OBJECTIVES:Recurrent mitral regurgitation (MR) after transcatheter edge-to-edge repair (TEER) poses significant clinical challenges, often requiring innovative solutions to address valve dysfunction. A technique combining anterior mitral leaflet laceration using the laceration of the anterior mitral leaflet to prevent outflow obstruction (LAMPOON) technique, followed by transcatheter mitral valve replacement may be a novel strategy for managing complex recurrent MR after TEER in patients not deemed to be surgical candidates. The purpose of this report is to describe 2 cases which used this technique. KEY STEPS:Preprocedural planning is crucial, and backup mechanical circulatory support should be considered. Native mitral valve is snared with electrocautery similar to the LAMPOON technique. The anterior leaflet is subsequently lacerated as close to the TEER device anteriorly as possible so that the device remains attached on the posterior valve to avoid left ventricular outflow tract (LVOT) obstruction. The transcatheter mitral valve is then deployed. POTENTIAL PITFALLS:Potential pitfalls include the following: 1) LVOT obstruction despite care taken to entrap the TEER device posteriorly; 2) paravalvular leak; and 3) hemodynamic collapse from acute MR. TAKE-HOME MESSAGES:Transcatheter electrosurgical laceration of the anterior leaflet of the mitral valve and subsequent placement of an Intrepid valve is an option to treat residual or recurrent MR in patients with prior TEER deemed not to be surgical candidates and/or patients with contraindication for a repeat TEER. Operators must plan for hemodynamic compromise and take care to lacerate the anterior leaflet as close to the device as possible to prevent LVOT obstruction.

Background: Treatment options for severe tricuspid regurgitation (TR) require a multimodal analysis of the tricuspid annulus (TA). Cardiac computed tomography (CT) is currently considered the gold standard for annular perimeter measurements, though three-dimensional transesophageal echocardiography (3D TEE) can yield similar results. As such, we sought to determine the accuracy and precision of 3D TEE imaging of the TA perimeter compared to CT imaging in outpatients with severe TR. Methods: Fifty-five patients were referred for multimodality workup for severe TR that included CT and 3D TEE. The 3D TEE imaging was performed in the mid-esophageal (ME) and transgastric views. A semiautomated software program was used to identify and measure the TA with additional manual optimization by the reader. These 3D TEE measurements were compared to cardiac CT imaging. Results: Out of 55 patients, 3 were excluded for hiatal hernias and 1 was excluded for severe kidney disease. Fifty-one studied patients had an average age of 76 ± 10 years with 59% female. The 3D TEE analysis of the TA perimeter demonstrated an excellent correlation with CT from the ME view, R = 0.88, and from the TG view, R = 0.86, with an average difference of approximately 8.5% when compared to CT. TEE inter-reader variability was approximately 6%, whereas CT variability was 1.4% Conclusions: The 3D TEE TA perimeter measurements are accurate when compared to CT with a variability of 8.5%. While CT remains more precise, 3D TEE imaging for TA sizing should be considered a near-equivalent modality to CT.