Key Imaging Factors for Transcatheter Management of Tricuspid Regurgitation: Device and Patient Selection

Abstract

The growing awareness of tricuspid regurgitation (TR) and the fast-expanding array of devices aiming to percutaneously repair or replace the tricuspid valve have underscored the central role of multi-modality imaging in comprehensively assessing the anatomical and functional characteristics of TR. Accurate phenotyping of TR, the right heart, and pulmonary vasculature via echocardiography, computed tomography, and, occasionally, cardiovascular magnetic resonance and right heart catheterization is deemed crucial in choosing the most suitable treatment strategy for each patient and achieving procedural success. In the first part of the present review, key imaging factors for patient selection will be discussed. In the ensuing sections, an overview of the most commonly used, commercially available systems for transcatheter repair/replacement will be presented, along with their respective selection criteria and information on intraprocedural imaging guidance; these are edge-to-edge repair, orthotopic and heterotopic replacement, and valve-in-valve procedures.

Keywords: heterotopic valve replacement; interventional echocardiography; interventional imaging; multimodality imaging; orthotopic valve replacement; structural heart imaging; structural interventional cardiology; transcatheter edge-to-edge repair; transcatheter tricuspid valve replacement; tricuspid regurgitation.

Figure 8

Screening for TTVR, key imaging features. Panel (A): TEE 3D volume of TV to assess TV annulus (diameters and perimeter) and basal RV diameter. Panel (B): CT evaluation of TV annulus (upper panels) in diastole (panel (B) top left) and systole (panel (B) top right), and RV at basal level in diastole (bottom left) and systole (bottom right); Evoque anchors are represented in light blue. Panel (C): working room assessment; RA and RV length are measured from a reformatted 4 chamber view. Panel (D): fluoroscopic reconstruction of implant projection derived from CT images; the distance between inferior vena cava and TVA centerline is measured; in this case it was 11.7 mm (>25 mm is considered a cut-off for non-feasibility). Panel (E): contrast CT, evaluation of position and distance of papillary muscles. CT computed tomography; IVC: inferior vena cava; RA: right atrium; RV: right ventricle; TEE: transesophageal echocardiography; TTVR: transcatheter tricuspid valve replacement; TV: tricuspid valve; TVA: tricuspid valve annulus.

Figure 9

Cardiac CT screening of candidate patient for Cardiovalve implantation: different take-off of the IVC and relationship between IVC and tricuspid annulus (a–c). Measurement of the distance between the tricuspid annular plane and the free-wall of the RV (d); systolic and diastolic dimensions of the annulus together with the evaluation of minimal and maximum diameter (e,f). CT: computed tomography; IVC: inferior vena cava; RV: right ventricle.

Figure 1

Tricuspid leaflet anatomy classification. (A) Tri-leaflet anatomy. (B) Bicuspid anatomy with a septal leaflet and a large anteroposterior leaflet. (C–E) Four-leaflet anatomy with a bipartite anterior, posterior or septal leaflet, respectively. (F) Five-leaflet anatomy with bipartite anterior and posterior leaflets. Abbreviations: A = anterior leaflet; P = posterior leaflet; S = septal leaflet; Ao = aorta. The pink circle denotes the position of the anterior papillary muscle.

Figure 2

Reconstruction of the TV annulus from a 3D dataset with indicated the antero-posterior and septo-lateral diameters, annular circumference and area.

Figure 3

Coaptation gap measurement on a multiplanar reconstruction of a 3D trans-esophageal echocardiography dataset – red, blue and green lines represent orthogonal reference planes (A); biplane commissural view (B); transgastric en-face view (C).

Figure 4

Right heart catheterization (RHC) in tricuspid regurgitation. (A) Example of RHC tracings in a case of TR in the absence of left heart disease. (B) Example of RHC tracings in TR secondary to left heart disease with elevated pulmonary capillary wedge pressure. Abbreviations: a: a-wave; c: c-wave; v: v-wave; x: x-descent; y: y-descent; RAP: right atrial pressure; PCWP: pulmonary capillary wedge pressure; RVSP: right ventricular systolic pressure; mPAP: mean pulmonary artery pressure.

Figure 5

Tricuspid regurgitation and cardiac implantable electronic devices (CIED). (A) TTE RV-focused four-chamber window (A1) and 3D evaluation (A2) of a CIED-related TR due to septal leaflet impingement; (B) TEE transgastric long-axis window (B1) and 3D assessment (B2) of a CIED-related TR due to a spiral-shaped trajectory of CIED interfering with anteroseptal coaptation; (C) TEER with two clips in a case of CIED-incidental TR: baseline TEE inflow–outflow window with biplane-derived four-chamber view showing a functional atrial TR with a posterior CIED (C1), tricuspid transcatheter edge-to-edge repair with 2 TriClip devices in anteroseptal (C2) and posteroseptal (C3) positions; (D) tricuspid transcatheter valve replacement (TTVR) with a Cardiovalve device in a CIED-related TR due to posterior leaflet impingement: baseline TEE inflow–outflow window with biplane-derived four-chamber view (D1) and TEE transgastric short axis (D3) showing a CIED-related TR; optimal result of Cardiovalve TTVR procedure with minimal residual regurgitation assessed at 2D-TEE (D2) and 3D-TEE (D4).

Figure 6

Intraprocedural guidance of T-TEER with TEE (A–H) or ICE (I,L–N). See text for details.

Figure 7

Evoque valve for TTVR. Panel (A). The Evoque valve. Atrial side (A) and ventricular side (V) of the valve, the skirt with nine anchors is indicated by the arrow. Panel (B). Evoque valve as it appears at TTE (*) in RV-focused 4 chamber view. Panel (C,D): TEE in mid-esophageal view (Panel (C)) and 3D view of the valve (*) from RA side (Panel (D)). AV: aortic valve; IAS: interatrial septum; RA: right atrium; RV: right ventricle.

Figure 10

An example of TricValve implantation with a 29 mm prosthesis in the SVC and 35 mm prosthesis in the IVC (a). TEE monitoring can be challenging for the superior prosthesis, and visualization is often suboptimal (b). The TEE can easily visualize inferior prosthesis delivery (c) and evaluate valve function and positioning (d). IVC: inferior vena cava; SVC: superior vena cava; TEE: transesophageal echocardiography.