Advances in Imaging for Tricuspid Transcatheter Edge-to-Edge Repair: Lessons Learned and Future Perspectives

Figures

• 

  Figure 1. Anatomy of the tricuspid valve.

• 

  Figure 2. Transthoracic echocardiogram in two dimensions. Parasternal long axis RV-inflow view (A,B). Since the interventricular septum and the coronary sinus ostium are not visualized, the leaflets imaged are the posterior (P) and anterior (A); Color doppler documented severe functional tricuspid regurgitation (TR).

• 

  Figure 3. Transthoracic echocardiogram in two dimensions. If the muscular interventricular septum along with the coronary sinus (CS) ostium are seen, then the leaflets visualized are the septal (S) and the anterior (A).

• 

  Figure 4. Transthoracic echocardiogram in two dimensions. (A) Apical four-chamber view: the septal leaflet (S) is seen adjacent to the septum and the anterior leaflet (A) adjacent to the right ventricular free wall; (B) Parasternal short-axis view: the anterior leaflet (A) is visualized next to the aorta and the posterior leaflet (P) on the opposite site, adjacent to the right ventricular free wall; (C) Apical four-chamber view with color-Doppler documenting tricuspid regurgitation (white arrow).

• 

  Figure 5. Cardiac implantable electronic device (CIED)-related tricuspid regurgitation (TR). Transthoracic echocardiogram, apical four-chamber view documents CIED RV lead (A,B, white arrows) and RA lead that cause relevant TR visible with Color-doppler (B, yellow arrow).

• 

  Figure 6. Transthoracic three-dimensional echocardiogram documenting tricuspid valve leaflets from atrial (left panel) and ventricular (right panel) perspectives. A = anterior leaflet, S = septal leaflet, P = posterior leaflet.

• 

  Figure 7. Transesophageal echocardiogram two-dimensional views (A,B): RV inflow-outflow view with biplane imaging; (C,D) deep esophageal 0° view) and multiplanar views (E,F) documenting flail anterior leaflet determining malcoaptation and severe tricuspid regurgitation with color Doppler (B,D,F). Ao = aorta, P = posterior leaflet, A = anterior leaflet, S = septal leaflet.

• 

  Figure 8. Two-dimensional transesophageal echocardiogram transgastric (TG) views. (A) TG short axis 30° documenting all three tricuspid valve leaflets in the open position during diastole; (B) in another patient, TG short axis 47° also with Color Doppler that documented functional tricuspid regurgitation due to leaflets tethering; (C) in another patient, TG short axis 32° also with color Doppler (D) with closed leaflets during systole documenting malcoaptation, especially between the anterior and septal leaflets, determining tricuspid regurgitation. The anterior leaflet (A) is in the far field, the posterior leaflet (P) is in the near field, and the septal leaflet (S) is on the right.

• 

  Figure 9. Transesophageal echocardiogram. (A) 3D en face imaging of the tricuspid valve acquired from a mid-esophageal commissural view with Z rotation: this is called the “surgeon’s view” and images the aorta and anterior leaflet (A) on top; (B) with Color Doppler documenting severe tricuspid regurgitation (TR). A = anterior leaflet, S = septal leaflet, P = posterior leaflet.

• 

  Figure 10. Assessment of TA dimensions by Cardiac Computed Tomography performed with a specific right–sided opacification protocol and by using multiplanar planes. (A) A planar cross-sectional area (short-axis) of TA that allows measurements of the TA area, perimeter, anteroposterior, and septal- lateral diameters. (B) Right-chambers morphology for the measurement of distance between the TA and the RV apex. (C) A transverse plane of the IVC. TA = tricuspid annulus, LV = left ventricle, AR = aortic root, AA = ascending aorta, PA = pulmonary artery, RA = right atrium, RV = right ventricle, LA = left atrium, IVC = inferior vena cava.

• 

  Figure 11. Cardiac magnetic resonance allows for the assessment of right ventricular (RV) function and tricuspid valve regurgitation by cine-imaging. (A) Four-chamber view of the heart. (B) Short-axis view of RV and LV. (C) Q-Flow sequences (example of pulmonary artery Q-flow assessment). (D) A typical analysis results table for Pulmonary Q Flow and RV function with important parameters for pre-procedural and post-procedural assessment. RA = right atrium, RV = right ventricle, LA = left atrium, LV = left ventricle, TA = tricuspid annulus, PA = pulmonary artery.

• 

  Figure 12. Intraprocedural monitoring by transesophageal echocardiography. (A) Transgastric short-axis view. Color Doppler is useful to guide positioning of the clip over the desired location relative to the regurgitant orifice. (B) Mid-esophageal commissural biplane view and (C) transgastric short-axis view: the position of the clip delivery system (CDS) with respect to the target lesion can be checked and corrected using 2D (single or biplane) and Color Doppler. (D) Transgastric short-axis view. The quality of leaflet grasp is verified by the limited leaflet mobility relative to the tips of the clip arms. A = anterior leaflet, S = septal leaflet, P = posterior leaflet.