Multi-Modality Imaging of the Tricuspid Valve: From Tricuspid Valve Disease to Catheter-Based Interventions

Fig. 1.. Tricuspid valve anatomy and tricuspid regurgitation classification (see introduction). Abbreviations: EROA, effective regurgitant orifice area; PISA, proximal isovelocity surface area; PM, pace maker; RA, right atrium; RV, right ventricle; TR, tricuspid regurgitation; TV, tricuspid valve; VC, vena contracta.

Fig. 2.. Applications of multiplanar reconstructions of 3D datasets of the tricuspid valve. (A) 3D multiplanar reconstruction of a stenotic tricuspid bioprosthetic valve, used to planimeter the residual bioprosthetic orifice area. (B) Multiplanar reconstruction of a 3D color-Doppler volume dataset for quantification of regurgitant vena contracta area. (C) 3D multiplanar reconstruction used to assess the transvalvular trajectory of a CIED-lead during the entire cardiac cycle and its relationships with leaflets and the subvalvular apparatus. (D) 3D multiplanar reconstruction used to planimeter the annular perimeter, area and diameters.

Fig. 3.. CMR long and short axis view of right heart and TV using bSSFP sequences.(A) RVOT view: in this view can be best appreciated pulmonary valve regurgitation and outflow tract. (B) 4 Chamber view: right ventricular inflow, RV and RA are visualized; the dotted orange line indicates the septo-lateral dimension of the TA. (C) RV 2 chamber view or inflow view, only the RA and RV are visualized; the dotted blue line represents the TA. (D) RV inflow/outflow view also called RV 3 chamber view, the dotted light green line shows the antero-posterior dimension of the TA. (E) 3D echocardiography of the TV showing a central coaptation defect in this case of functional TR; all three leaflets are visualized. (F) CMR short-axis systolic view of the TV of the same case of (E): the dotted lines represent the different TA dimension as depicted in (B–D) (but acquired in diastolic phase to measure the largest TA diameters). (G) CMR short-axis diastolic view of TV, the three leaflets are easily identified. (H) bicaval righ atrial view, prescribed using a cutting plane passing through the RA, the IVC and the SVC; in this view both IVC and SVC dimensions can be assessed, the HV is also visualized.…

Fig. 4.. Common CMR artefacts in patients with TV disease. Magnetic susceptibility and metallic artefacts are frequent in patients with TR; they are caused by the presence of ferromagnetic components of PM leads (arrowheads) or triclip device (*) and can affect image quality. Arrhythmias, like atrial fibrillation is often associated with severe TR and can cause motion artefacts, as shown in the right column. Abbreviations: CMR, cardiac magnetic resonance; PM, pace maker; TR, tricuspid regurgitation; TV, tricuspid valve.

Fig. 5.. Tricuspid regurgitation and RH chambers remodelling. In (A–D) primary TR are shown. Upper row (A,C,E,G) show diastolic images, while the lower row (B,D,F,H) systolic images. The black arrow indicates the TR regurgitant jets. Orange line: anterior/posterior leaflet; blue line: septal leaflet. Light green line: septolateral diameter of TA in diastole. Dotted green line: right atrium. Dotted yellow lines: RV walls dilatation. Primary TR is caused by leaflets abnormalities. A case of flail leaflet is shown in (A,B): right chambers can be normal or mildly dilated because of recent onset of TR; in Ebstein anomaly (C,D) the TR is caused by displacement of septal leaflet (blue line) with distortion of normal right chamber anatomy. Secondary TR can be atrial or ventricular mediated. In atrial functional TR there’s a prevalent enlargement of the basal wall of RV ((E), yellow dotted line), of the TA (light green line) and RA ((F), green dotted line). In ventricular functional TR, the RV is globally enlarged ((G), yellow dotted line) causing leaflets tenting (H). Abbreviations: RA, right atrium; RH, right heart; RV, TA, tricuspid annulus; TR, tricuspid regurgitation; TV, tricuspid valve.

Fig. 6.. CT multiplanar 3D reconstruction of TA. MPR is used to visualize the insertion points of the TV leaflets into the TA. SAX view of TA (A) is obtained by placing two cut-planes passing through TA antero-posterior diameter (B) and septum-to-lateral diameter (C). However, the TA is not planar, and 2D evaluation of TA fails to represent the real shape of TA. In (D), the saddle-shape of TA can be appreciated. 3D TA is obtained tracing point by point the insertions of TV leaflets into the TA. In this way, 3D perimeter and area can be calculated. Abbreviations: CT, computed tomography; MPR, multiplanar reconstruction; RA, right atrium; RV, right ventricle; SAX, short axis; TA, tricuspid annulus; TV, tricuspid valve.

Fig. 7.. Right coronary artery evaluation prior to TVI. With adequate patient preparation and a dedicated triphasic protocol it is possible to evaluate RCA and RH at the same time. (A,B) 3D volume rendering of both right and left chambers; the coronary arteries are highlighted in red, the RCA (*) has a normal course in the AV groove. (C) Relationship between RCA (*) and TA. Distance between proximal and distal RCA (yellow arrows) can be calculated. Proximal or distal RCA of 2 mm, may be associated with high risk of RCA impingement during TV annuloplasty. (D,E) Distance between RCA and TA in LAX views. In (D) the course of RCA is into the AV groove, while in (E) the RCA course is superior the TA. In (F), multiplanar reconstruction algorithm of RCA is shown; the distance between the RCA and the annulus is indicated with orange arrows. Abbreviations: AV, atrioventricular; LAX, long axis; MPR, multiplanar reconstruction; RCA, right coronary artery; RH, right heart; SAX, short axis; TA, tricuspid annulus; TV, tricuspid valve; TVI, tricuspid valve intervention.

Fig. 8.. Steps of intraprocedural imaging. (A,B) Insertion of the steerable guide catheter into the right atrium. (C–E) Advancement of the clip delivery system through the steerable guide catheter into the right atrium and steering towards tricuspid valve plane. (F) Axial alignment of the clip delivery system. (G) Clip rotation and alignment to the coaptation line. (H,I) Leaflet grasping. (L–N) Check of adequate leaflet tissue grasping. (O,P) Assessment of residual TR. (Q) Clip deployment. (R) advancement of a second clip into the right atrium.