Echocardiographic Imaging to Guide Tricuspid Interventions

Figures

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  Figure 1. Transesophageal imaging levels for tricuspid valve assessment. The 4 imaging levels, mid-esophageal, deep esophageal, transgastric, and deep transgastric, can be used to perform a comprehensive assessment of tricuspid valve anatomy and function. From each recommended imaging level, the columns show essential planar imaging, volumetric or three-dimensional imaging, and functional or hemodynamic imaging. (Reproduced with permission from Hahn RT, Saric M, Faletra FF, et al. Recommended Standards for the Performance of Transesophageal Echocardiographic Screening for Structural Heart Intervention: From the American Society of Echocardiography. J Am Soc Echocardiogr 2022; 35(1): 1-76.). Abbreviations: 3D, three-dimensional; CW, continuous wave; LA, left atrium; LV, left ventricle; ME, mid esophageal; MPR, multiplanar reconstruction; PW, pulsed wave; RAA, right atrial appendage; RV, right ventricle; TEE, transesophageal echocardiography; TR, tricuspid regurgitation; TV, tricuspid valve.

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  Figure 2. Three-dimensional (3D) imaging of the tricuspid valve. A comprehensive assessment of tricuspid valve morphology and anatomy requires 3D imaging. The guideline suggested 3D rendered en face image of the tricuspid valve places the septal leaflet in the far field (panel a); however, this typically requires z-plane rotation that can be inconsistently performed and thus lead to misidentification of leaflets. Instead, from most mid-esophageal views obtained from 0 to 90° of mechanical rotation, the anterior leaflet is the far-field leaflet (panel b) resulting in an image similar to that obtained from the transgastric short-axis views. From any 3D volume acquisition, multiplanar reconstruction (panels c and d) of 2D images allows for precise imaging of leaflets, coaptation gaps, and regurgitant orifice location and size. Abbreviation: 2D, two-dimensional; A, anterior leaflet; AV, aortic valve; P, posterior leaflet; S, septal leaflet; TEE, transesophageal echocardiography.

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  Figure 3. Multiplanar reconstruction (MPR) of the tricuspid valve. 3D MPR is an ideal imaging modality to assess the coaptation gaps and leaflet lengths at specific locations along the septal line of coaptation. In this example, the anterior-septal (A-S) leaflet coaptation gap and leaflets lengths can be measured by positioning the red plane across that coaptation zone in the short-axis view. The same has been performed for the posterior-septal (P-S) coaptation zone. Abbreviation: 3D, three-dimensional.

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  Figure 4. Possible anatomic considerations for transcatheter tricuspid valve interventions. The favorable, feasible, and unfavorable anatomy for tricuspid transcatheter edge-to-edge repair and orthotopic transcatheter tricuspid valve replacement devices are shown. Abbreviations: CIED, cardiovascular implantable electronic device; EROA, effective regurgitant orifice area; TR, tricuspid regurgitation.

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  Figure 5. Tricuspid valve leaflet morphology. Both two-dimensional (panel a) and 3D (panel b) imaging from the transgastric view allow for imaging of the leaflets, scallops, and chordae, essential for determining TEER feasibility and likelihood of procedural success. Similar information can be obtained using 3D MPR (panel c). In this instance, there is a four-leaflet valve with an anterior (A), septal (S) and 2 posterior leaflets (P1 and P2). Abbreviations: 3D, three-dimensional; MPR, multiplanar reconstruction; TEER, transcatheter edge-to-edge repair; TV, tricuspid valve.

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  Figure 6. TriClip generation 4 devices. The TriClip system uses a right heart-specific guide and delivery system and the fourth generation implants: NT and XT clip sizes (4 mm width; 9 [NT] and 12 [XT] mm arm length), a wider implant size of 6 mm is available with both arm lengths (6 mm width; 9 [NTW], and 12 [XTW] mm arm length). The 2 rigid arms of cobalt-chromium alloy have flexible nitinol-based “grippers” with longitudinally arranged frictional elements; 4 for the NT and NTW, and 6 for the XT and XTW. There is independent and controlled gripper action and an active locking mechanism. There are 2 working catheters for positioning the device, the clip delivery system (CDS) and the guide catheter; for optimal steerability, the 2 markers of the CDS must “straddle” the tip of the guide.

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  Figure 7. Pascal edge-to-edge devices. The PASCAL system for either mitral or tricuspid TEER has 3 working catheters with the device attached to the distal end of the inner implant catheter. With this design, there is a high range of motion and maneuverability without dictating the relative positions of the catheters. The device itself is nitinol throughout with 2 spring-loaded, curved paddles (10 mm wide for P10 and 6 mm wide for ACE) with horizontally arranged retention elements along the distal end of the paddles and a central spacer of varying diameters (smaller for the ACE). The nitinol clasps can be controlled individually, enabling either simultaneous or independent leaflet capture and with passive closing mechanism (based on nitinol shape memory). (Note: numbers represent mm). Abbreviation: TEER, transcatheter edge-to-edge repair.

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  Figure 8. Intraprocedural imaging for tricuspid edge-to-edge repair (T-TEER). The introduction of the device (red asterisk) into the right atrium (panel a) can be performed using either 2D or 3D imaging. The latter often allows for continuous imaging as the device is steered toward the tricuspid annulus. Once near the tricuspid annulus, either biplane imaging or 3D MPR may be used to confirm trajectory and position (panel b). Positioning and orienting the device can be performed using 3D imaging (with or without color Doppler) or can be confirmed from a short-axis transgastric view (panel c). While in the right atrium, the individual grasping elements are tested (panel d). The device is then advanced into the right ventricle (panel e) while continuously imaging using biplane imaging or 3D rendered imaging; the latter allows continuous tracking of the orientation of the device arms. Once under the leaflets, any imaging plane or modality (2D or 3D) that allows for imaging of the device and leaflets can be used (panel f). Finally, after leaflets are grasped, both transgastric and mid-esophageal views are used (panel g) to ensure both adequate grasp, as well as tricuspid regurgitation…

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  Figure 9. Intraprocedural imaging for orthotopic transcatheter tricuspid valve replacement. In this example of an orthotopic TTVR, EVOQUE, the method of ensuring positioning and anchor capture are shown. Following anchor exposure and flip (panel a), 3D MPR must be used to ensure positioning the anchors below the leaflets and annulus, but above the papillary muscles. Rotation of the green and red planes from the short-axis view permits a systemic method of visualizing all 9 anchors. In the next step, ventricular expansion of the device (panel b), this MPR rotation is repeated and fine-tuning of device position is performed. Once the device position is satisfactory and all leaflets are seen above the anchors with the anchor tips below the annulus, the atrial portion of the device is expanded and the device released (panel c). Abbreviations: 2D, two-dimensional; 3D, three-dimensional; MPR, multiplanar reconstruction; TEE, transesophageal echocardiography; TTVR, transcatheter tricuspid valve replacement.