RVOT Deployment of EVOQUE Transcatheter Tricuspid Valve Replacement System: Overcoming Inadequate Implant Depth

Figures

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  Figure 1. Left panel: The overall working length of the EVOQUE delivery device is 78 mm from the inflexion point to the capsule and 90 mm from the inflexion point to the tip of the nose cone. Right panel: The minimum working length to accommodate the EVOQUE delivery device is an RA >50 mm and an overall working length of RA and RV >100 cm. However, other factors affect the capsule position from the TV annulus, including the IVC–TVA offset and the EV distance from the TVA. Abbreviations: EV, Eustachian valve; IVC, inferior vena cava; RA, right atrium; RV, right ventricle; TV, tricuspid valve; TVA, tricuspid valve annulus.

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  Figure 2. Left panel: TEE images. (a) RV inflow view. Posterior (P) and anterior (A) leaflets visible. This also shows a prominently long Eustachian valve (∗). (b) RV outflow view. Septal (S) and anterior (A) leaflets visible. (c and d) Color demonstrating torrential tricuspid regurgitation. Right panel: (e and f) CT cardiac angiography with measurements of the TVA. (g and h) CT overlay images generated using 3Mensio (Pie Medical imaging, Netherlands) showing the relationship of IVC and TV annulus in (g) coplanar view and (h) en face view showing there is overlap of the IVC and TV annulus, which is predictive of a favorable TTVR anatomy for right-sided femoral approach. Abbreviations: CT, computed tomography; EV, Eustachian valve; IVC, inferior vena cava; RV, right ventricle; TEE, transesophageal echocardiography; TTVR, transcatheter tricuspid valve replacement; TV, tricuspid valve; TVA, tricuspid valve annulus.

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  Figure 3. (a–c) CT cardiac angiography with measurements of the RV and RA in diastole and systole. Favorable RA height (>60 mm) and RV working room to accommodate the EVOQUE capsule. (d) Three-dimensional reconstruction reveals a prominent EV and distance to the TVA of 24.6 mm. In our cases, we have observed that EV–TVA distance <25 mm would favor a left femoral approach. (e) IVC centerline to TVA distance of 31.9 mm. In our experience, centerline IVC–TVA distance of <40 mm could potentially lead to inadequate working room length, and we favor a left-sided approach. In this case, despite a large RA height, we were unable to gain adequate RA height from the right- and left-sided approach. Abbreviations: CT, computed tomography; EV, Eustachian valve; IVC, inferior vena cava; RA, right atrium; RV, right ventricle; TVA, tricuspid valve annulus.

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  Figure 4. Left panel top image: 3D intracardiac image and CT simulation demonstrating inadequate right atrial height and a deep capsule position. CT predicted adequate right atrial height of >60 mm. However, the large EV prevented adequate right atrial height and the capsule was too deep. Multiple maneuvers to gain height were insufficient from the right femoral approach, and we converted to a left femoral venous approach. Despite the left femoral approach, the capsule was still deep in the RV at 3.3 cm from the TV annulus and 2.3 cm from the systolic coaptation plane. Left panel bottom image: CT simulation demonstrating the position of the capsule in relation to the EV (∗) and the TV systolic coaptation. Right image: Capsule deep in the RV. The white interrupted line represents the approximate plane of the TV annulus. Abbreviations: A, anterior leaflet; CT, computed tomography; EV, Eustachian valve; P, posterior leaflet; RV, right ventricle; TV, tricuspid valve.

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  Figure 5. Anatomical requirement for anterior tilted deployment of EVOQUE valve. The crimped valve length from the loading tabs to the anchor tips is between 51 mm and 54 mm based on the valve size. At final release, the distance from the loading tabs to the flipped anchor tips is 17 mm. If the capsule edge is <35 mm below the annulus, the anchors will have adequate room to flip to the TV hinge points by final release without chordal entrapment. Abbreviation: TV, tricuspid valve.

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  Figure 6. Left image: ICE showing the PA trajectory with the posterior aspect of the capsule edge just beneath the systolic coaptation plane. Right image: Capsule gap created with a pronounced PA trajectory to gain RA height. The white interrupted line represents the approximate plane of the TV annulus. Abbreviations: ICE, intracardiac echo; PA, posterior-to-anterior; RA, right atrium; TV, tricuspid valve.

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  Figure 7. Left image: ICE multiplanar reconstruction images. The anchors are peeking out of the capsule with a pronounced anterior trajectory and the tip of the capsule at the anterior septal commissure in the RVOT. Right image: The entire system is retracted posteriorly to avoid chordal entanglement while maintaining the anterior trajectory. Abbreviations: A, anterior; ICE, intracardiac echo; L, lateral; P, posterior; RVOT, right ventricle outflow tract; S, septal.

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  Figure 8. Progressive exposure of the anchors maintaining the anterior trajectory from 10 to 90 degrees while adding primary flex to correct the anterior trajectory and keeping posterior anchors at proper height to encourage leaflet capture and minimize possible entaglement with sub valve structures. The valve frame shortens as more anchors are exposed. The white interrupted line represents the approximate plane of the TV annulus. Abbreviation: TV, tricuspid valve.

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  Figure 9. Top panel: Progressive exposure of the anchors and ventricular flip of the anchors while simultaneously adding primary flex to correct the anterior trajectory and become coaxial to the TV annular plane. The white interrupted line represents the approximate plane of the TV annulus. Bottom panel: ICE multiplanar reconstruction images demonstrating the progressive ventricular flip of the EVOQUE anchors. Abbreviation: ICE, intracardiac echo; TV, tricuspid valve.

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  Figure 10. Left image: Ventricular expansion of the EVOQUE frame demonstrating engagement of the anchors evenly beneath the anterior, posterior, septal, and lateral portions of the TV annulus. Right image: Ventricular expansion of the EVOQUE frame. White interrupted line represents the approximate plane of the TV annulus. There is a mild anterior-to-posterior trajectory, which was corrected by the final release. Abbreviation: TV, tricuspid valve.

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  Figure 11. Left image: ICE image of the valve deployed. Right image: Fluoroscopy of the valve deployed. The white interrupted line represents the approximate plane of the TV annulus. Abbreviation: ICE, intracardiac echo; TV, tricuspid valve.