Transesophageal Echocardiography and Intracardiac Echocardiography to Guide EVOQUE

Figure 1. Baseline TEE Imaging (A) Demonstrates short axis view of the tricuspid valve via a gastric image on transesophageal echocardiography. The 3 leaflets, septal (S), anterior (A), and posterior (P), are visualized along with the coaptation gap. (B) The long-axis view of the right ventricle on gastric images shows the posterior and anterior leaflet again with the large coaptation gap along with torrential tricuspid regurgitation.

Figure 2. Visual Summary, Providing a Step-by-Step Imaging Guide to the Procedure (A) Baseline gastric long-axis view of the right ventricle (RV) with torrential tricuspid regurgitation (TR). (B) Short-axis view of the tricuspid valve with large coaptation gap. (C) Two-dimensional (2D) intracardiac echocardiography (ICE) demonstrating good visualization of the leaflets. (D) Two-dimensional (2D) transesophageal echocardiography and gastric images to guide wire placement in the RV apex and posteriorly. (E) 3D multiplanar reconstruction (MPR) on ICE being used to maneuver the delivery system into the RV. (F) Device anchors noted on 3D MPR by ICE; also noted are the 9 device anchors in the RV. (G) Ventricular expansion of the device. (H) After atrial expansion, results demonstrate no residual TR. (I) 3D image of the newly implanted EVOQUE device.

Figure 3. Baseline ICE Imaging (A) 2D ICE showing the biplane of the RV inflow/outflow view. Visualized are the posterior and anterior leaflets along with the septal and lateral commissures. (B) 3D MPR using ICE again demonstrating the tricuspid valve anatomy. In this view, it is critical to visualize the leaflets adequately to ensure visibility during leaflet capture by the anchors. Abbreviations as in Figures 1 and 2.

Figure 4. Guiding Wire and Delivery System (A) Gastric image on transesophageal echocardiography (TEE) demonstrating wire placement with the curl of the wire facing posteriorly. (B) 3D MPR on ICE is then visualized to guide the delivery system into the RV considering the anterior, posterior, septal, and lateral orientation of the device. Abbreviations as in Figures 1 and 2.

Figure 5. ICE for Leaflet Capture and Visualization of Anchors (A) 3D MPR and ICE is used to visualize the anchors at 90 degrees and their relationship to the tricuspid leaflets. (B) The anchors now pointed atrially, with clear visualization of leaflet capture by the anchor. The 9 anchors are visible in this image, and the green MPR line is used to rotate through each of the anchors to assess leaflet capture. Abbreviations as in Figures 1 and 2.

Figure 6. Gastric Images to Visualize Anchors In this case, it was difficult to visualize the posterior anchors owing to acoustic shadowing. Therefore, the gastric views were used on TEE to assess these anchors. (A) Gastric short-axis view of the tricuspid valve on TEE with the anchors, paying special attention to the 10 o’clock anchor (biplane line, yellow dot). (B) 3D MPR using gastric TEE images demonstrates that there is no leaflet capture at the 10 o’clock anchor. This anchor will therefore need to be adjusted to ensure there is leaflet capture. Abbreviations as in Figures 1, 2, and 4.

Figure 7. Device Deployment Under ICE (A) After confirmation of leaflet capture by all 9 anchors, the device is expanded ventricularly as can be visualized on the 3D MPR and ICE image. (B) The device is fully expanded with no residual TR. (C) 3D TEE of the newly implanted EVOQUE valve. Abbreviations as in Figures 1, 2, and 4.

Figure 8. Challenging Intraprocedural Images Because of to Pacemaker Lead (A) The gastric images in this case were challenging because of the pacemaker wire (star). The implanting team should ensure that the coil of the guidewire is again pointed posteriorly. (B) 3D MPR and ICE are challenging, but it is important to differentiate between the pacemaker wire (yellow arrow) and the delivery system. The red arrow shows the device capsule edge in the RV. Abbreviations as in Figures 1 and 2.

Figure 9. Despite the Difficult Imaging, the Valve Was Successfully Deployed (A) ICE 3D MPR shows the pacemaker wire pinned between the posterior aspect of the valve and the EVOQUE device. (B) 2D ICE also showing the pacemaker wire pinned between the posterior aspect of the native valve and the EVOQUE device. There is now only mild residual valvular TR. Abbreviations as in Figures 1 and 2.