Multi-Modality Imaging for Interventions in Tricuspid Valve Disease

Figure 1. Tricuspid valve and right ventricular anatomy. The figure displays an anatomic specimen with a view of the tricuspid valve from the right ventricle (courtesy of Dr. Monique R.M. Jongbloed and Ing. L.J. Wisse, Department of Cardiology and Department of Anatomy and Embryology, Leiden University Medical Center, Leiden, The Netherlands). AL, anterior leaflet; RV, right ventricle; RVOT, right ventricular outflow tract; PL, posterior leaflet; SL, septal leaflet.

Figure 2. Typical imaging features of primary vs. secondary tricuspid regurgitation. *Both RV and RA dilatation can cause TA dilatation. RA, right atrium; RV, right ventricle; TA, tricuspid annulus; TV, tricuspid valve.

Figure 3. Echocardiographic assessment of the tricuspid valve. (A) displays the apical four-chamber view where the anterior and septal leaflet of the TV can be visualized. (B) shows the parasternal long-axis view of the RV where the anterior and posterior leaflet of the TV can be imaged. In the parasternal short-axis view (C), the posterior and anterior leaflet of the TV can be imaged. (D) shows the mid-esophageal four-chamber view where the anterior and septal leaflet of the TV can be observed. (E) displays the transgastric RV inflow view where the posterior and anterior leaflet of the TV can be imaged. From the mid-esophageal RV inflow-outflow view (F) the anterior and posterior leaflet of the TV can be imaged. From the transgastric TV short-axis view (G), all the TV leaflets can be simultaneously visualized. Similarly, 3D images of the TV acquired from the apical (H) and mid-esophageal (I) four-chamber view can show all the TV leaflets simultaneously. AL, anterior leaflet; AoV, aortic valve; MV, mitral valve; PL, posterior leaflet; RA, right atrium; RV, right ventricle; SL, septal leaflet; TV, tricuspid valve.

Figure 4. Echocardiographic assessment of the tricuspid annulus and right ventricular dimensions. The figure presents a summary of the main echocardiographic measurements of RV and TA dimensions. EDA, end-diastolic area; EDV, end-diastolic volume; ESV, end-systolic volume; LV, left ventricle; PV, pulmonary valve; RA, right atrium; RV, right ventricle; RVD, right ventricular diameter; TA, tricuspid annulus; TV, tricuspid valve.

Figure 5. Multi-detector row computed tomography assessment of the tricuspid valve and surrounding structures. (A) displays the MDCT assessment of TA anatomy and dimensions. (B) shows the functional assessment of the RV using computed tomography feature-tracking longitudinal strain. (C) shows the spatial relation of the TA (red circle) with the RCA (green line). This is an important information to assess the feasibility and plan the location where to implant the anchors (light blue cylinders) of the Cardioband device. (D) shows the assessment of the distance between the RCA and the TA on two predicted positions where the anchors of the Cardioband device will be placed. LA, left atrium; LV, left ventricle; MDCT, multi-detector row computed tomography; RA, right atrium; RCA, right coronary artery; RV, right ventricle; TA, tricuspid annulus.

Figure 6. Assessment of right ventricular remodeling with cardiovascular magnetic resonance. CMR represents the gold standard to measure RV volumes (A,B) and mass (A). The analysis of T1 mapping allows also the investigation of the stress-induced remodeling by the RV on its anterior and posterior insertion points (arrows) on the interventricular septum (C). (D) illustrates the assessment of RV systolic function using CMR feature-tracking RV free-wall and global longitudinal strain. CMR, cardiac magnetic resonance; LV, left ventricle; RV, right ventricle.

Figure 7. Grading of tricuspid regurgitation severity. The figure illustrates the main qualitative, semi-quantitative and quantitative parameters of tricuspid regurgitation severity. PISA, proximal isovelocity surface area; RA, right atrium; TV, tricuspid valve.

Figure 8. Summary of the main echocardiographic parameters of right ventricular systolic function. The figure illustrates conventional [TAPSE (A), S' (B), and FAC (C)] and advanced [RV EF (D,E), global and free-wall RV longitudinal strain (F)] echocardiographic indices of RV systolic function. EDA, end-diastolic area; EDV, end-diastolic volume; ESA, end-systolic area; ESV, end-systolic volume; RV, right ventricle; TAPSE, tricuspid annular plane systolic excursion.

Figure 9. Multimodality imaging for intra-procedural guidance of a Cardioband procedure on the tricuspid valve. MDCT data displaying the predicted position of the anchors of the Cardioband device (stars) can be aligned with real-time echocardiographic data (A) during the procedure. The MDCT-echocardiography fusion imaging permits a better alignment of the delivery system (arrow) to place the anchors in the predicted position on the TA (B) avoiding potential complications such as RCA compression or damage. TR severity and TA dimensions can be assessed during the procedure with multi-planar reconstruction echocardiography (C) to monitor the result. Orthogonal fluoroscopic views can be used to locate the delivery system (arrows), the anchors of the Cardioband device and their relative position to the RCA (D). Moreover, intracardiac echocardiography can be very helpful to align the delivery system (arrows) to the TA and aim for an optimal position of the anchors (E), especially in the case of challenging transesophageal echocardiographic views or difficult anatomy. MV, mitral valve; RA, right atrium; RCA, right coronary artery; RV, right ventricle; TV, tricuspid valve.