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The success of transcatheter tricuspid valve intervention (TTVI) procedures is heavily dependent on the quality of intraprocedural imaging. However, optimal image quality with transesophageal echocardiography (TEE) can be challenging due to the anterior position of the tricuspid valve, the anatomical structure of the leaflet, and the presence of prostheses.1Davidson C.J. Abramson S. Smith R.L. et al.Transcatheter tricuspid repair with the use of 4-dimensional intracardiac echocardiography.JACC Cardiovasc Imaging. 2022; 15: 533-538https://doi.org/10.1016/j.jcmg.2021.01.029Crossref PubMed Scopus (19) Google Scholar Hence, there is a need for adjunctive imaging modalities to enhance visualization and facilitate guidance of TTVI procedures.2Alkhouli M. Eleid M.F. Michellena H. Pislaru S.V. Complementary roles of intracardiac and transoesophageal echocardiography in transcatheter tricuspid interventions.EuroIntervention. 2020; 15: 1514-1515https://doi.org/10.4244/EIJ-D-19-01078Crossref PubMed Scopus (10) Google Scholar, 3Gleason P.T. Inci E.K. Ram P. et al.Use of steerable guide catheter to improve intracardiac ultrasound in transcatheter tricuspid valve edge-to-edge repair.J Soc Cardiovasc Angiogr Interv. 2022; 1100454https://doi.org/10.1016/j.jscai.2022.100454Abstract Full Text Full Text PDF Scopus (0) Google Scholar, 4Hagemeyer D. Ali F.M. Ong G. Fam N.P. The role of intracardiac echocardiography in percutaneous tricuspid intervention: a new ICE age.Interv Cardiol Clin. 2022; 11: 103-112https://doi.org/10.1016/j.iccl.2021.09.006Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar Although 2-dimensional intracardiac echocardiography (ICE) imaging has been proven to be successful in tricuspid transcatheter edge-to-edge repair (TEER) procedures,5Eleid M.F. Alkhouli M. Thaden J.J. et al.Utility of intracardiac echocardiography in the early experience of transcatheter edge to edge tricuspid valve repair.Circ Cardiovasc Interv. 2021; 14e011118https://doi.org/10.1161/circinterventions.121.011118Crossref Google Scholar 3-dimensional (3D) ICE imaging offers incremental benefits in confirming device location which could be essential for guiding safe and effective tricuspid valve intervention. Here, we describe the early use and role of 3D ICE in TTVI. We also propose an imaging quality grading system to determine the adequacy of TEE or ICE images to guide the TTVI procedure. We retrospectively identified a total of 24 consecutive TTVI procedures for severe-or-more tricuspid regurgitation (TR) between July 2020 and December 2023 at St. Francis Hospital, Roslyn, NY: n = 6 for transcatheter tricuspid valve replacement (TTVR; EVOQUE, Edwards Lifesciences) and n = 18 for TEER (MitraClip, Abbott Vascular). Among them, we included 11 procedures (45.8%; 4 for TTVR and 7 for TEER) which were guided by both intraprocedural 3D ICE and TEE. The study was approved by the institutional review board with a waiver of informed consent. TEE was performed using a Philips Epic CVx Echocardiography System (Philips Healthcare) fitted with a 3D matrix array X8-2t transducer. Three-dimensional ICE (VeriSight, Philips Healthcare) was used as an adjunct at the operator's discretion in these selected cases, often due to preemptive limited visualization of tricuspid leaflets on TEE. During the procedure, while the interventional cardiologist performs ICE catheter manipulation, the echocardiologist operates the console connected to both ICE and TEE probes, alternating their use and displaying images in 3D live multiplanar reconstruction views which allow 360° visualization of leaflet captures and devices. Three-dimensional multiplanar reconstruction was routinely used for both TTVR and TEER to confirm the position and orientation of the devices, whereas biplane images were often useful during TEER to confirm satisfactory grasping and insertion of leaflets in a higher resolution. The ICE device was positioned in the midright atrium with slight flexion and rotated until the leaflets came into view. To assess leaflet visualization for capturing in TTVR and grasping in TEER, 2 cardiologists (L.W. and D.S.) graded TEE and ICE images in a blinded fashion as excellent, good, fair, or poor, based on predefined criteria shown in Figure 1. Data are presented as median (interquartile range) or mean ± standard deviation according to their distribution. The median age was 83 years (70-84) and 70% were female. TTVI was successful in all cases without procedural complications. The severity of TR was significantly reduced from 4+ or more to trace in all 4 TTVR cases (pre- vs post-TTVI TR grade: 4 4-4 vs 1 1-1, respectively; P = .02). Notably, TR severity was also improved by at least 1 grade in all TEER cases (pre: 4.8 ± 0.2 vs post: 3.4 ± 0.3; P < .001). There were substantial interrater agreements for the quality of the TEE (Kappa = 0.79, P < .001) and ICE images (Kappa = 0.74, P = .005). All ICE images were graded as "excellent" (9/11) or "good" (2/11), whereas no TEE images were graded as "excellent" and 27.3% (3/11) were "poor" due to hiatal hernia or preexisting MitraClip device. Factors affecting the TEE images were preexisting MitraClip (8/11), prior mitral valve replacement (2/11), mitral annular calcification (2/11), pacing wire (1/11), and hiatal hernia (1/11). The quality of the ICE images was better than TEE in 81.8% (9/11) of the cases. Compared with TTVI procedures done without ICE (n = 13), there was no significant difference in procedural success (100% for both), procedural time (ICE vs non-ICE: 150.0 ± 55.7 minutes vs 160.8 ± 48.9 minutes; P = .62) or TR reduction in grade (ICE vs non-ICE: 2.4 ± 0.5 vs 1.5 ± 0.3; P = .116), although ICE guidance resulted in significantly less severe-or-more residual TR compared with non-ICE guidance (9.1% vs 53.9%, respectively; P = .03). The current study demonstrates the following: (1) the feasibility and safety of using 3D ICE to guide TTVR and TEER; (2) not infrequently encountered limited quality of TEE images to guided TTVI; (3) superior visualization of tricuspid leaflets and prosthesis/device by 3D ICE than TEE in majority of cases; and (4) potential benefits of ICE guidance to improve procedural outcomes when the quality of TEE images is not excellent. Furthermore, we propose a novel imaging quality grading system to determine the adequacy of TEE or ICE images to guide the TTVI procedure, which needs further validation. Although the current single-center study with a small sample size lacks generalizability, this hypothesis-generating study highlights the increasing utilization of adjunctive ICE and its unique role in facilitating leaflet visualization for capturing and grasping. Further studies with larger sample sizes and control groups are warranted to better define the role of ICE versus TEE or combined ICE and TEE imaging during TTVI. Ziad A. Ali reports institutional grants from Abbott, Abiomed, Acist Medical, Boston Scientific, Cardiovascular Systems Inc, Medtronic, Opsens Medical, Philips, Shockwave Medical; personal fees from Amgen, Astra Zeneca, Boston Scientific; equity from Elucid, Lifelink, Spectrawave, Shockwave, and Vital Connect. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose. This work was not supported by funding agencies in the public, commercial, or not-for-profit sectors.
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