Multimodality Imaging for Transcatheter Tricuspid Regurgitation Interventions: Novel Approaches to the Forgotten Valve

Abstract

Tricuspid regurgitation (TR) poses a significant healthcare burden and is a major concern for patients who experience debilitating symptoms and face a poorer prognosis. Cardiologists are showing renewed interest in TR, as the previous belief that it was merely a bystander of left-sided heart disease has evolved. As a result, more transcatheter techniques addressing TR are emerging. Although a clear impact on mortality from these transcatheter tricuspid valve interventions (TTVI) has not yet been demonstrated, the improvement in symptoms and quality of life for patients is substantial, leading to increased use of these procedures in clinical practice. In this review, we focus on multimodality imaging as an essential tool for quantifying TR severity, assessing right ventricular (RV) function, understanding the underlying mechanisms, selecting the appropriate intervention, and ensuring thorough and accurate preprocedural planning to minimize complications.

Keywords: cardiac computed tomography; cardiac magnetic resonance; echocardiography; multimodality imaging; transcatheter interventions; tricuspid regurgitation; tricuspid valve.

FIGURE 1

On the right: the heart pictured in a vertical positioning as a “Valentine's heart,” on the left: the heart pictured with the long axis rotated to the real “apex” position. The “anterior” leaflet is truly located antero‐superior, the “septal” leaflet is posterior, and the “posterior” leaflet is inferior.

FIGURE 2

On the left: TTE four chambers view with and without color Doppler, optimal view to measure the 2 dimensional (2D) “VC”; On the right: TOE 3D reconstruction of 3D EROA. 2D indicates 2 dimensional; EROA, effective regurgitant orifice area; TOE, transesophageal echocardiography; TTE indicates transthoracic echocardiography; VC, vena contracta.

FIGURE 3

TTE four chambers view at tele‐diastole. Red two‐headed arrow pointing the measurement for the TV anulus. TTE indicates transthoracic echocardiography; TV, tricuspid valve.

FIGURE 4

On the left: TOE TG TV oriented view: green oval indicating septal leaflet, purple oval indicating posterior leaflet, orange oval indicating anterior leaflet and blue circle indicating the antero‐septal papillary muscle. On the right: TOE TG TV‐oriented 3‐dimension live view. TG indicates trans gastric; TOE, transesophageal echocardiography; TV, tricuspid‐valve.

FIGURE 5

TOE mid‐esophageal 60° RV inflow‐outflow view with simultaneous biplanar imaging. On the left image simultaneous biplanar imaging is positioned to obtain a 90° view for the S and the A. On the right image the simultaneous biplanar imaging is positioned to obtain a 90° view for the S and the P. A indicates anterior leaflet; P, posterior leaflet; RV, right ventricle; S, septal leaflet; TOE, transesophageal echocardiography.

FIGURE 6

TOE TG view color Doppler and simultaneous biplane imaging that shows a “central” regurgitation (see GLIDE score). TG indicates trans gastric; TOE indicates transesophageal echocardiography.

FIGURE 7

Multi‐plane reconstruction of the IVC to measure the distance from the right atrium and the diameter of the IVC to select the right size for heterotopic TV implantation. IVC indicates inferior vena cava; TV, tricuspid‐valve.

FIGURE 8

Anulus measurement in CT with multi plane reconstruction. (A) antero‐superior diameter; (B) septo‐lateral diameter; (C) multiplane reconstruction with measurement of the entire anulus. CT indicates computed tomography.

FIGURE 9

Rendering of the right heart and right atrium with the RCA (*) running in the atrio‐ventricular groove. RCA indicates right coronary artery.

FIGURE 10

Short axis view of the RCA displaying its entire cursus. Red circle indicating the posterior part of the annulus where the distance between RCA and the anulus can shorten up to 1 mm. RCA indicates right coronary artery.