The Use of 3D-Echo in Edge-to-Edge Percutaneous Tricuspid Valve Repair

Figure 1. 3D zoom without and with color of torrential atrial and ventricular TR. Panels (A,B): 3D zoom TEE of the TV from the mid-esophageal window, in a patient with torrential atrial TR, showing tricuspid annulus dilatation, causing a large coaptation gap, associated with a broad TR jet. Panels (C,D): 3D zoom TEE of the TV from the mid-esophageal window in a patient with ventricular TR due to tethered septal leaflet, resulting in severe TR. TEE, transesophageal echocardiography; TV, tricuspid valve; TR, tricuspid regurgitation.

Figure 2. 3D MPR showing a trileaflet tricuspid valve. To improve spatial orientation, landmark anatomical surrounding structures have been included in the dataset. MPR, multiplanar reconstruction; A, anterior leaflet; P, posterior leaflet; S, septal leaflet.

Figure 3. 3D-zoom, en-face view of the TV, with and without color, showing a restricted septal leaflet due to CIED lead (white star), causing TR. CIED, cardiac implantable electronic device; TR, tricuspid regurgitation; TV, tricuspid valve.

Figure 4. 3D-TEE MPR to measure the VCA. After locking the orthogonal planes, the green plane is positioned at the level of the VC width in the red and blue plane. After careful adjustment, the VCA can be visualized and can be measured by direct planimetry in the green box. TEE, transesophageal echocardiography; MPR, multiplanar reconstruction; VC, vena contracta; VCA, vena contracta area.

Figure 5. Live 3D helps maneuver the SGC inside the RA. IAS, interatrial septum; SGC, steerable guide catheter; RA, right atrium; SVC, superior vena cava.

Figure 6. 3D-zoom MPR to orient the Triclip (white star). Panel (A): The green and red planes indicate the designated location between the anterior and septal leaflets. Panel (B): Once the optimal site of clip deployment has been established, 3D MPR helps to advance the Triclip across the TV annulus plane. MPR, multiplanar reconstruction; TV, tricuspid valve.

Figure 7. Live 3D helps to continuously monitor the advancement of the Triclip system (white star) across the TV annulus plane. Once the Triclip system has crossed the valve plane, it is crucial to reassess adequate orientation, as septal or lateral dive can occur while advancing the system in the RV. TV, tricuspid valve; RV, right ventricle.

Figure 8. 3D-zoom MPR to check adequate grasping and effective TR reduction. Panel (A): As shown in the orthogonal planes, both leaflets were grasped with good insertion. Panel (B): Despite a good grasping, TR was not sufficiently reduced. MPR, multiplanar reconstruction; TR, tricuspid regurgitation.

Figure 9. 3D-zoom MPR to assess TV repair result. Panel (A): After deployment, Triclip looks stable and adequately attached to both leaflets. Panel (B): 3D color shows a reduction in TR, with only mild residual insufficiency. TV, tricuspid valve; TR: tricuspid regurgitation.

Figure 10. Adjunctive 3D ICE imaging during Triclip procedure. Panel (A): The proximity of the ICE catheter to the TV plane allows for a better visualization of the TV leaflets. Panel (B): 3D ICE is a supplementary imaging modality that is helpful during leaflet grasping and determining appropriate leaflet insertion. ICE, intracardiac echocardiography; TEE, transesophageal echocardiogram; TV, tricuspid valve.