An 87-year-old Caucasian female with massive functional TR (grade IV/V) was referred for percutaneous tricuspid valve (TV) repair, based on multiple hospitalizations with right-sided acute heart failure, poor response to diuretic therapy, and high surgical risk (EUROSCORE 11.46%, Clinical Risk Score for Mortality 35%, Clinical Risk Score for Morbidity 59%). Her medical history included permanent atrial fibrillation, single-chamber pacemaker implantation, and percutaneous repair of severe MR, 2 years prior. Despite successful MR reduction, no effect on the severity of TR was observed. Since the pacemaker lead was not attached to any leaflet and did not interfere with the closure of the TV, the pathogenesis of TR was attributed to annular dilatation. Due to several comorbidities including stage 3B chronic kidney disease, type 2 diabetes, and frailty, she was deemed very high risk. The heart team suggested percutaneous TV repair. Upon admission, physical examination showed marked peripheral oedema, jugular venous distension, and an irregular heartbeat. The patient complained of shortness of breath on minimal exertion, had a low Kansas City Cardiomyopathy Questionnaire (KCCQ) Score of 21.9, a 6-min walk distance (6MWT) of 275 m and NT-proB-type natriuretic peptide (NTproBNP) of 2082 pg/mL. Transthoracic echocardiography (TTE) and TOE confirmed massive TR (), as measured by biplane vena contracta of 16 mm and regurgitant orifice area of 82 mm2. Regurgitation volume amounted to 82 mL. The right chambers were significantly enlarged [right atrial indexed volume 66.4 mL/m2; right ventricular (RV) basal diameter 48 mm], whereas TV annulus was dilated (38 mm). Furthermore, RV function was impaired [tricuspid annular plain systolic excursion (TAPSE) 10 mm, fractional area change 30%, lateral wall tissue Doppler 8.5 cm/s], and RV systolic pressure considerably increased (50 mmHg) (). Left ventricular function was normal. The low body mass index of 20.1 was attributed to cardiac cachexia and further increased the procedural risk, but made for a good echo window in TTE. Particularly the parasternal long-axis RV inflow view and the short-axis ‘aortic’ view best depicted TV anatomy with visualization of all three leaflets upon gentle tilting of the probe (). Therefore, we decided to use TTE as the main guiding method of percutaneous TV repair, complementary to fluoroscopy. As both methods were used in alternation, the echocardiographer was not exposed to unnecessary radiation. Considering that it was our first procedure with transthoracic guidance, we still opted for general anaesthesia and placement of a TOE probe, which only served as bail-out in case of imaging difficulties, and result confirmation. In hindsight, the TOE images proved to be inferior to the aforementioned TTE views, as especially the transgastric window was of poor quality. In view of the good long-time result after percutaneous mitral valve repair using the MitraClip™ system (Abbott Medical) in this patient and local expertise, a decision was made to use the recently approved TriClip™ XT device (Abbott Medical) (). After cannulation of the right femoral vein, the steerable guide catheter was advanced into the right atrium under fluoroscopic guidance. Then, by using bi-plane parasternal views, the TriClip™ delivery system was advanced into the right ventricle () and the clip was positioned and released between the anterior and septal (SL) leaflets (), where the main body of TR jet was present. As the big coaptation gap of 7 mm could not be covered with one clip, a second clip was implanted and successfully placed between the medial scallop of the posterior leaflet (PL) and the SL () and led to a reduction to moderate TR (II/V), while the TV pressure gradient only rose to 2 mmHg. During these movements, we paid attention to the pacer lead position and avoided dislodgement. The patient was extubated in the cath lab. The reminder of her hospital stay was uneventful with considerable diuretic dose reduction at discharge. One month follow-up confirmed successful downgrading from massive (IV/V) to moderate (II/V) TR (), with improvement of RV systolic pressure (50–42 mmHg), RV function (TAPSE 10–17 mm), and decrease in right atrium (66.4–58.9 mL/m2) and TR volume (82–23 mL). More importantly, the patient reported improvement of symptoms (New York Heart Association class III-II) and quality of life (QoL) (6MWT 275–360 m, KCCQ Score 21.9–36.1). Interestingly enough, liver and kidney values also improved and NTproBNP dropped to 1483 pg/mL.