Real-Time Monitoring and Step-by-Step Guidance for Transcatheter Tricuspid Annuloplasty Using Transesophageal Echocardiography

Figures

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  Figure 1. The K-ClipTM system. (a) The delivery module. (b) The guide sheath and its corresponding control module. (c) The clamp arms and the tapping screw in between.

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  Figure 2. The main steps of K-Clip™ implantation. (a): The opening clamp and the tapping screw-shaped anchor; (b): the tapping screw-shaped anchor is inserted into the middle of the posterior TA and pulled back to bring the surrounding annular tissue into the clamp; (c): the clamp is closed to plicate the TA and achieve bicuspidization of the TV.

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  Figure 3. Introducing the guidewire. (a): Mid-esophageal bicaval view (transducer angle at 70–110°), 2D TEE guiding the Super Stiff guidewire through the superior vena cava to the inferior vena cava (red arrow); (b): 3D TEE of the same view. LA, left atrium; RA, right atrium; SVC, superior vena cava.

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  Figure 4. Advancing the guide sheath. (a): Three-dimensional mid-esophageal bicaval view, the guide sheath (red line) slowly advancing along the guidewire (red arrow) to the lower third of the right atrium at about 1 cm from the inferior vena cava; (b): the same view showing the guide sheath after withdrawing the Super Stiff guidewire (red line). SVC, superior vena cava.

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  Figure 5. Adjusting the delivery catheter. (a): Three-dimensional adjusted mid-esophageal bicaval view (slight clockwise/counterclockwise rotation of the probe from the mid-esophageal bicaval view) demonstrating the head of the delivery catheter (red arrow) pointing into the right atrium above the anteroposterior TA junction (TA shown in red dotted line); (b): the same view showing the head of the delivery catheter pointing at the anteroposterior TA junction. SVC, superior vena cava.

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  Figure 6. X-Plane work plane of K-Clip™ implantation. X-Plane work plane showing tapping screw (red arrow) anchored into the predetermined TA location (delivery catheter shown in red dotted line, posterior TA shown in blue dotted line). LA, left atrium; RA, right atrium; Ao, aorta.

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  Figure 7. Three-dimensional work plane of K-Clip™ implantation. Three-dimensional work plane confirming tapping screw (red arrow) anchored at the target TA location (posterior TA shown in blue dotted line, clip arms shown in red dotted line). RA, right atrium.

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  Figure 8. Clamping of annular tissue. (a): Three-dimensional work plane showing the clip arms aligned parallel to the tangent line with the tricuspid annulus (clip arms are shown as red dotted lines, anchor is indicated by a red arrow); (b): 3D work plane showing the target TA tissue is lifted and slowly clamped (blue area indicates lifted TA tissue); (c): 3D work plane showing the multilayer structure of the TA tissue and anchor clutched in the clip arms.

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  Figure 9. Three-dimensional CDI demonstrating TR jet before and after K-Clip™ implantation. (a): Three-dimensional CDI showing severe TR; (b): 3D CDI showing residual mild-moderate TR after transcatheter tricuspid annuloplasty. TR, tricuspid regurgitation.

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  Figure 10. Measuring TR VCA before and after K-Clip™ implantation. (a): VCA showing severe TR; (b): VCA showing residual mild-moderate TR after transcatheter tricuspid annuloplasty.

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  Figure 11. Three-dimensional comparison of TA morphology before and after K-Clip™ implantation. (a): Three-dimensional TEE work plane showing the TA morphology before annuloplasty; (b): the same view showing the TA (red dotted line) and clip position (red arrow) after intervention.

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  Figure 12. Comparison of TA and TV dimensions before and after K-Clip™ implantation. (a): TA and TV measurements before annuloplasty; (b): TA and TV measurements after intervention.