*3.2.2 Heterotopic tricuspid valve implantation*

Heterotopic TTVI refers to the implantation of a competent valve in a position different from the native tricuspid valve. The inferior vena cava (IVC), generally in combination with the superior vena cava (SVC), are the sites of choice, leading to the ventricularization of the right atrium [17]. Therefore, this approach does not address the TR itself, but prevents from severe systemic venous congestion related to right HF. As a palliative therapy, is it usually indicated in severely symptomatic patients with end-stage HF and massive or torrential TR not deemed candidates for other invasive approaches. Compared with orthotopic TTVI, this procedure is simpler, avoids the introduction of prosthetic material in the inlet of the RV and the position of the valve does not interfere with pacemaker or defibrillator electrodes, if present [58]. On the contrary, clinical impact of untreated TR, right atrial ventricularization, persistent right atrial volume overload and potentially increased RV afterload is unknown. This group of devices includes SAPIEN, TRICVALVE and TRICENTO (**Figure 4D**–**F**).
