Echocardiographer-Led Combined Transjugular Intracardiac Echocardiography and Transesophageal Echocardiography for Tricuspid Transcatheter Edge-to-Edge Repair.

Figures

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  Figure 1. Screening TEE Demonstrating Suboptimal Visualization of the Tricuspid Valve Leaflets for T-TEER Grasping TEE = transesophageal echocardiography; T-TEER = tricuspid transcatheter edge-to-edge repair.

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  Figure 2. Transjugular ICE Catheter Insertion and Procedural Workflow Configuration (A) 10-F venous sheath with a figure-of-eight suture/stopcock assembly for postprocedure tensioning and hemostasis. (B) Sterile handling of the ICE catheter using full-body sterile drape. (C) Sterile, modified (end caps removed) 90-cm plastic Swan-Ganz sheath for sterile protection of the ICE catheter. (D) Swan-Ganz sheath elongated over the ICE probe and secured at the proximal end with sterile adhesive dressing. (E) ICE catheter tip introduced into the 10-F venous sheath. (F) Sterile adhesive dressing applied to the distal end of the Swan-Ganz sheath. (G) Final RIJ ICE access site configuration for intraprocedural RIJ ICE imaging. ICE = intracardiac echocardiography; RIJ = right internal jugular.

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  Figure 3. Intraprocedural Workflow for Echocardiographer-Led Combined RIJ ICE and TEE ICE = intracardiac echocardiography; RIJ = right internal jugular; TEE = transesophageal echocardiography.

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  Figure 4. TEE Baseline Assessment TEE baseline assessment of the tricuspid valve (2D and color flow Doppler) using midesophageal (A), deep esophageal (B, C), and transgastric (D) views. TEE = transesophageal echocardiography.

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  Figure 5. RIJ ICE Catheter Insertion and Manipulation (A) TEE guidance of ICE catheter insertion into the RA. (B) TEE 3-D en-face view of the tricuspid valve to optimize positioning of the ICE catheter tip above the intended grasping site. (C) Fluoroscopic guidance of the ICE catheter into the RA. (D) Transjugular ICE catheter is rotated approximately 90° counterclockwise (while standing at the head of the bed facing the patient, clutch knob facing ceiling) and retroflexed to align the insonation beam perpendicular to the tricuspid annulus. (E) RIJ ICE assessment of the tricuspid valve with 2D and (F) color flow Doppler biplane imaging. (G) Multiplanar reconstruction of the tricuspid valve using 3-D ICE. ICE = intracardiac echocardiography; RA = right atrium; RIJ = right internal jugular; TEE = transesophageal echocardiography.

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  Figure 6. Echocardiographer-Led Intraprocedural Imaging for T-TEER Using Combined RIJ ICE and TEE (A) TEE guidance of CDS insertion. (B) TEE assessment of coaxiality and clip descent across the tricuspid valve. (C) TEE confirmation of clip orientation using the TG view. (D to F) RIJ ICE biplane imaging for confirmation of leaflet grasp, closure of retention elements, and device closure. CDS = catheter delivery system; ICE = intracardiac echocardiography; RIJ = right internal jugular; TEE = transesophageal echocardiography; TG = transgastric; T-TEER = tricuspid transcatheter edge-to-edge repair.

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  Figure 7. Postgrasp Assessment Postgrasp assessment using RIJ ICE (A and B), TEE (C, midesophageal; D, transgastric), and fluoroscopy (E). ICE = intracardiac echocardiography; RIJ = right internal jugular; TEE = transesophageal echocardiography.

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  Figure 8. Figure-of-Eight/Stopcock Assembly to Obtain Hemostasis After Removal of the Right Internal Jugular Sheath

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  Figure 9. Transjugular ICE “Candy Cane” Maneuver to Overcome Far-Field Imaging Limitations From the SVC Approach in Marked Right Atrial Dilatation (120° Tip Retroflexion With Microadjustments of Lateral Flexion and Omniplane) ICE = intracardiac echocardiography; SVC = superior vena cava.

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  Visual Summary. Echocardiographer-Led Combined Transjugular Intracardiac Echocardiography and Transesophageal Echocardiography for Tricuspid Transcatheter Edge-to-Edge Repair (A) Combined transjugular ICE-TEE configuration from the head of the bed demonstrating favorable ergonomics. (B) Fluoroscopy of the combined transjugular ICE-TEE approach. (C) Intraprocedural transjugular ICE biplane imaging of the T-TEER grasping view. (D) Intraprocedural assessment of the tricuspid valve after clip deployment using transjugular ICE biplane imaging with color flow Doppler overlay. ICE = intracardiac echocardiography; TEE = transesophageal echocardiography; T-TEER = tricuspid transcatheter edge-to-edge repair.