Echocardiographic guidance in transcatheter tricuspid valve interventions

Figures

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  Fig. 1. Multiple parametric methods to determine severity of tricuspid regurgitation (TR). A, B Torrential TR as demonstrated by 2D effective regurgitant orifice area (EROA) of 0.95 cm2 and TR regurgitant volume of 73 mL which are derived from proximal isovelocity surface area (PISA) method and TR signal tracing. C Evidence of slightly asymmetric vena contracta diameters (10 and 12 mm; double-headed white arrows) in 3D multiplanar reconstruction imaging, which is consistent with severe TR (average vena contracta diameter of 11 mm). D Presence of systolic flow reversal (blue arrow) from hepatic vein in every cardiac cycles is a specific sign of significant TR

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  Fig. 2. The mid-esophageal right ventricle (RV) inflow-outflow view. A Using simultaneous biplane imaging at RV inflow-outflow view (50°–70°), sweeping the orthogonal imaging plane (dotted line) from posterior (P; left side of primary view) to anterior (A; right side of primary view, near the aortic valve) visualizes the coaptation of the posterior-septal (P-S), and anterior-septal (A-S) commissures respectively. B The color flow Doppler from biplane imaging helps to localize the tricuspid regurgitation (TR) jet, which is more significant in central and anteroseptal aspect. RA, right atrium; RV, right ventricle; TV, tricuspid valve

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  Fig. 3. Tricuspid valve (TV) leaflet anatomy in transgastric (TG) short-axis view (0°–30°). A The 3D multiplanar reconstruction imaging at this level allows in-depth assessment of number of leaflets (anterior leaflet, A; posterior leaflet, P; septal leaflet, S), leaflet morphology (thickness, calcification), chordal attachment, and pacing/defibrillator lead involvement if any. The red plane is cutting through A-P leaflets; the blue plane is cutting through A-S leaflets; the green plane is the en face view of TV. B The TV short-axis view with aortic valve at 5 o’clock is essential to identify the maximum coaptation gap, which is localized at central orifice measured 3.2 mm. C The TV anatomy in TG short-axis view (0°–30°) showing a four-leaflet TV with anterior (A) and septal (S) leaflets, and two posterior leaflets (P1 and P2). D The TV imaging from TG view (30°) is guided and further optimized by using two-chamber inflow-outflow view of right heart (120°). RA, right atrium; RV, right ventricle; RVOT, right ventricular outflow tract

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  Fig. 4. Echocardiographic and schematic visualization of the TriClip system (Abbott Laboratories) for tricuspid valve (TV) edge-to-edge repair. A Simulated transesophageal echocardiogram (TEE) image of a standard bicaval view. B Simulated cardiac structures adjacent to TEE probe, highlighting its anatomical relationship to the TV. C Intraprocedural TEE image (bicaval view) with the TriClip clip delivery system (asterisk) positioned. D The 3D TEE image of the bicaval view, rotated 90° counterclockwise to profile the TV and TriClip delivery system (asterisk). E Schematic diagram illustrating the primary steering motions of the TriClip system: advancement/withdrawal (A/W), catheter rotation (Rot), flexion/extension (F/E), and lateral/septal (L/S) control. A, anterior leaflet; AP, anteroposterior commissure; AS, anteroseptal commissure; AV, aortic valve; IAS, interatrial septum; IVC, inferior vena cava; LA, left atrium; P, posterior leaflet; PS, posteroseptal commissure; RA, right atrium; S, septal leaflet; SVC, superior vena cava

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  Fig. 5. A Once the device delivery system has approached just above the tricuspid valve plane, the right ventricular (RV) inflow-outflow mid-esophageal (ME) view (50°–70°) and orthogonal four-chamber view (150°–180°) assists in directing device trajectory and location. B The optimal trajectory pathway should be perpendicular to the tricuspid annular plane which could be well demonstrated from 3D multiplanar reconstruction of RV inflow-outflow ME view (with embedded video). A, anterior leaflet; AV, aortic valve; P, posterior leaflet; RA, right atrium; S, septal leaflet; TV, tricuspid valve

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  Fig. 6. The transgastric (TG) 3D multiplanar reconstruction (MPR) views. A The TG 3D MPR view (0°–30°) focusing on tricuspid valve short-axis level provides pivotal information on clip arm orientation, in which the clip arm is rotated to 2–8 o’clock orientation (with embedded video). B Once the clip delivery system is 2 to 3 mm below the tricuspid valve, the clip arms would be opened and clip arm orientation has to finely adjust using TG 3D MPR view. A, anterior leaflet; P, posterior leaflet; S, septal leaflet

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  Fig. 7. A The 3D multiplanar reconstruction or B biplane mid-esophageal right ventricle inflow-outflow view (50°–70°) provides adequate imaging guidance for leaflet capture. C The clips are gradually closed and make sure the tissue bridge (arrow) has been well established from transgastric short axis view of TV (with embedded video). A, anterior leaflet; P, posterior leaflet; S, septal leaflet

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  Fig. 8. The tricuspid valve (TV) leaflet lengths at (A) baseline and (B) after clipping status should be compared and leaflet insertion should be calculated. For TriClip XTW system, the recommended leaflet lengths should be at least 9 mm or above. The septal leaflet insertion is 14 mm and anterior leaflet insertion is 11 mm, which are adequate for secure grasping. A, anterior leaflet; AV, aortic valve; P, posterior leaflet; RA, right atrium; RV, right ventricle; S, septal leaflet

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  Fig. 9. The 3D intracardiac echocardiography imaging can serve as important tool when the transesophageal echocardiography imaging is suboptimal to guide tricuspid valve (TV) leaflet grasping. The use of –45°/+ 45° view together with a left flexion could help to get the adequate images for anteroseptal leaflet grasping in this situation. A TV leaflet capture by TriClip. B Adequate TV leaflet capture. A, anterior leaflet; P, posterior leaflet; RA, right atrium; RV, right ventricle; S, septal leaflet

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  Fig. 10. A The vena contracta diameter of post-clipping tricuspid regurgitation (TR), effective regurgitant orifice (ERO) area and (B) TR regurgitant volume, (C) hepatic vein Doppler interrogation, and (D) tricuspid valve (TV) mean gradient should be properly assessed after clip implantation. The final parameters of vena contracta 3 mm, ERO area 0.05 cm2 and regurgitant volume 6 mL, absence of systolic flow reversal at hepatic vein, and mean gradient 1 mmHg demonstrated a successful Both transcatheter tricuspid edge-to-edge repair procedure with significant TR reduction. A, anterior leaflet; AV, aortic valve; P, posterior leaflet; PG, ****; RA, right atrium; RV, right ventricle; VTI, ****

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  Fig. 11. The LuX-Valve Plus (Ningbo Jenscare Biotechnology) is a novel radial force–independent orthotopic transcatheter tricuspid valve replacement (TTVR) with (A) the component of delivery system and (B) LuX-Valve Plus implant. C The LuX-Valve Plus is implanted through single jugular venous access under transesophageal echocardiography and fluoroscopy guidance

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  Fig. 12. Having successful access into right ventricle, 3D multiplanar reconstruction of A mid-esophageal view (50°–70°) paired with B, D orthogonal four-chamber view (in 3D photorealistic imaging) provide essential images to ensure the LuX delivery system maintain appropriate co-axiality (red dotted line) and C central crossing through the tricuspid annulus (blue dotted line). A, anterior leaflet; P, posterior leaflet; RA, right atrium; RV, right ventricle; S, septal leaflet; TV, tricuspid valve