Tricuspid Leaflet Gap-Reduction Maneuvers During Transcatheter Tricuspid Valve Repair

Figures

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  Figure 1. Case 1: Use of Ventilator-Assisted Valsalva Maneuver (A) Transesophageal echocardiogram with transgastric short-axis view of the tricuspid valve showing preprocedural septolateral gaps of 0.7 to 1.0 cm (yellow arrows) (Video 1). Color Doppler 3-dimensional (3D) vena contracta area (VCA) was 1.44 cm2(B), consistent with torrential tricuspid regurgitation. Transgastric short-axis view with biplane of the tricuspid valve during transcatheter tricuspid edge-to-edge repair (T-TEER) after ventilator-assisted Valsalva maneuver, showing a reduction of the coaptation gaps to 0.3 to 0.6 cm (C) (Video 2), which can be also seen on postprocessed 3D transgastric short-axis view of the tricuspid valve (D) (Video 3). After a total of 3 T-TEER clips were placed (E), the 3D VCA was reduced to 0.13 cm2(F), consistent with mild TR. AV = aortic valve.

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  Figure 2. Case 2: Use of PEEP and Chest Pressure (A) Baseline preprocedural transesophageal echocardiographic transgastric short-axis view of the tricuspid valve (Video 4) shows an anteroposterior (AP) gap of 4.9 cm (red arrow), with septolateral (SL) gaps between 1.5 and 1.8 cm (yellow arrows). (B) Color Doppler 3D VCA was 3.28 cm2, consistent with torrential tricuspid regurgitation. (C,D) During T-TEER, transgastric short-axis view and postprocessed 3D short-axis view of the tricuspid valve after the use of positive end-expiratory pressure (PEEP) and chest pressure show a reduction of the coaptation gaps to 0.5 to 0.7 cm (yellow arrows) (Video 5). After successful T-TEER with 2 devices (E), the 3D VCA was reduced to 1.5 cm2(F), a >50% reduction from baseline. RA = right atrium; RV = right ventricle; other abbreviations as in Figure 1.

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  Figure 3. Case 3: Use of PEEP (A) Baseline transgastric short-axis view shows a septolateral gap of 0.38 cm with dense chordae. (B) Tricuspid valve leaflets close at the annular plane (midesophageal RV inflow view with biplane) with a relatively short septal leaflet. (C) Color Doppler 3D VCA was 0.75 cm2, consistent with severe tricuspid regurgitation (TR). (D) During T-TEER, after the anterior leaflet was grasped, the device could not be maneuvered close enough to the septum for an adequate grasp of the septal leaflet (midesophageal RV inflow view with biplane) (Video 6). (E) PEEP was used to reduce the tricuspid annular (TA) diameter (green arrows) (Video 7). (F) After single-device T-TEER, the 3D VCA was reduced to 0.15 cm2, consistent with mild TR. Abbreviations as in Figures 1 and 2.