Author + information
- Received June 12, 2018
- Revision received July 24, 2018
- Accepted July 25, 2018
- Published online March 4, 2019.
- Rebecca T. Hahn, MDa,∗ (, )
- Michael Nabauer, MDb,
- Michel Zuber, MDc,
- Tamim M. Nazif, MDa,
- Jörg Hausleiter, MDb,
- Maurizio Taramasso, MD, PhDc,
- Alberto Pozzoli, MDc,
- Isaac George, MDa,
- Susheel Kodali, MDa,
- Vinayak Bapat, CTha and
- Francesco Maisano, MDc
- aColumbia University Medical Center, New York Presbyterian Hospital, New York, New York
- bMedizinische Klinik und Poliklinik I, Klinikum der Universität, Munich, Germany
- cHeart Center, Zürich University Hospital, University of Zürich. Zürich, Switzerland
- ↵∗Address for correspondence:
Dr. Rebecca T. Hahn, Columbia University Medical Center, New York-Presbyterian Hospital, 177 Fort Washington Avenue, New York, New York 10032.
Interest in the transcatheter solutions for tricuspid regurgitation has gained momentum given the limited indications for and high in-hospital mortality associated with isolated surgical intervention. Advanced imaging techniques to guide the procedures are the key to technical success. The following overview of the imaging requirements of selected devices is intended to give a glimpse into the complex procedures now possible with imaging guidance.
Interest in the transcatheter solutions for tricuspid regurgitation (TR) has increased in recent years with the recognition of the impact of secondary TR on outcomes (1–4) and the high in-hospital mortality associated with isolated tricuspid valve (TV) surgery (5,6). A number of devices to address symptomatic severe TR are in early development or in trials with 1 device, the Cardioband (Edwards Lifesciences, La Jolla, California), receiving the Conformité Européene (CE) mark award in April 2018. Transcatheter TV devices currently under investigation or development (Table 1) can be roughtly divided into those treating annular dilatation (i.e., Trialign [Mitralign, Tewksbury, Massachusetts], Cardioband [Edwards Lifesciences, Irvine, California], TriCinch [4TECH, Galway, Ireland], Millipede [Boston Scientific Corp., Marlborough, Massachusetts], and Cardiac Implants [Cardiac Implants LLC, Tarrytown, New York]), those approaching leaflet malcoaptation (i.e., MitraClip [Abbott Vascular, Santa Clara, California], PASCAL [Edwards Lifesciences], and FORMA [Edwards Lifesciences]), heterotopic valve implantation (i.e., CAVI [caval valve implants] [Tricentro, New Valve Technology, Muri, Switzerland] and Tricentro), and transcatheter TV replacements (i.e., GATE, NaviGate Cardiac Structures [Lake Forest, California], Trisol [Trisol Medical, Yokneam, Israel], valve-in-valve [ViV]). These devices use different access sites to reach the TV: the superior vena cava (SVC), inferior vena cava (IVC), and transtrial. Other devices in development may access the pericardial space. This list is not exhaustive because there is ongoing development of new devices.
Pre-procedural planning typically requires a multimodality approach including transthoracic and transesophageal echocardiography (TEE), multislice computed tomography (MSCT), and occasionally cardiac magnetic resonance (CMR) imaging. A brief review of important anatomy and use of multimodality imaging is included; however, this review will focus on intraprocedural imaging. Six procedures exemplify some of the imaging successes and challenges in this field (Central Illustration): 2 annuloplasty devices (Trialign and Cardioband), 2 leaflet devices (the edge-to-edge leaflet repair and the FORMA), transcatheter tricuspid replacement device (GATE valve), and transcatheter tricuspid ViV procedure. The 2 annular devices require different imaging skills to identify the tricuspid annulus and implant a device either through the annulus alone, or into the underlying myocardium. The 2 leaflet devices require precise imaging of the tricuspid leaflets or precise implantation of an anchor into the right ventricular (RV) myocardium. The 2 replacement devices require imaging of valve positioning within the native TV annulus or a bioprosthetic TV. As new devices and new imaging tools (i.e., large field-of-view 3-dimensional [3D] intracardiac echocardiographic catheters and multivendor fusion imaging) are developed, intraprocedural imaging protocols will continue to evolve.
TV Anatomy and Pre-procedural Imaging
Pre-procedural imaging of the right heart and TV by echocardiography, MSCT, and CMR are used to assess TV morphology, assess RV and left ventricular (LV) size and function, precisely define the tricuspid annulus and its relationship to adjacent structures (i.e., right coronary artery [RCA]), characterize the vena cavae (for access or device implantation), identify the location and complexity of the subvalvular apparatus, as well as quantifying regurgitation. Specific structural imaging is dependent on the device. For the annular devices, the area and perimeter of the annulus, as well as the depth of the annular tissue (from leaflet hinge-point to RCA) are important measurements for sizing, positioning, and avoiding complications. For the edge-to-edge device, pre-procedural MSCT and CMR are not typically performed. In addition to the aforementioned anatomy, for the FORMA device, imaging is used to measure the distance from the valvular annulus to the right ventricular apex and a target anchoring site is selected based on a sagittal TV imaging planes on MSCT reconstruction (8). For transcatheter tricuspid replacement, sizing algorithms continue to be developed; however, 3D TEE and MSCT imaging have both been used to assess the average annular diameter (based on perimeter as well as area) with minimal oversizing required given the conical shape of the device and presence of an atrial brim. Selected patients may undergo pre-operative imaging for tricuspid ViV. MSCT imaging may be particularly helpful in confirming the size of an existing bioprosthesis. MSCT and CMR may also be useful in evaluating the cardiac structures, the feasibility of various possible access routes, and the orientation of the TV plane with respect to the planned access.
Trialign TV Annuloplasty
The Trialign system (Mitralign Inc., Tewksbury, Massachusetts) attempts to replicate the results of the classic or modified Kay bicuspidization procedure (9,10). The Percutaneous Tricuspid Valve Annuloplasty System (PTVAS) for SCOUT (Symptomatic Chronic Functional Tricuspid Regurgitation) trial was the first U.S. prospective, single-arm, multicenter, early feasibility study to complete its 15 patient enrollment and report the 30-day result (NCT02574650) (11). The Trialign device achieved: 1) 93% procedural success, no procedural mortality or stroke, successful delivery and retrieval of the device delivery system, and proper placement of the device in all patients; 2) quantitative reduction of tricuspid annular measurements and TR severity with concomitant increase in LV forward stroke volume; and 3) improvement in quality of life measures. The Trialign system uses a transjugular approach to introduce a deflectable guide and wire delivery catheter beneath the annulus. A pair of pledgeted sutures are implanted across the posterior leaflet annulus and the 2 sutures drawn together to achieve plication of the annulus with reduction of TR achieved by improving the coaptation of the anterior leaflet and septal leaflets.
Pre-procedural imaging includes a combination of transthoracic and TEE as well as MSCT to evaluate the tricuspid annular shelf and RV morphology. Subannular myocardial bridges or shallow annular shelf (<2 to 4 mm) may make the implantation difficult or result in device detachment. Implantation of the Trialign device relies primarily on TEE (Table 3) (11). Before the implantation of the device, a guidewire is placed in the RCA to help identify its location relative to the tricuspid annulus. Two 14-F sheaths are introduced into the right jugular vein for delivery of the device. A deflectable guide catheter is introduced to position a wire delivery catheter beneath the annulus, between the posterior and septal tricuspid leaflet commissures. Before crossing the annulus, both 2-dimensional (2D) and 3D TEE imaging is used to visualize the wire delivery catheter and confirm: 1) adequate annular depth, (>2 to 4 mm from the hinge of the leaflet); 2) distance from the RCA; and 3) direction (into the right atrium). An insulated radiofrequency (20 to 30 W for ∼3 s) wire is passed through the tissue of the annulus and wire position (both depth and location) is confirmed by TEE. The wire is snared in the right atrium, exteriorized, and a pledget delivery catheter is introduced over the wire and across the annulus. Fluoroscopy and TEE guide withdrawal of the pledget deliver catheter and seating of the RV side of the pledget. The proximal (atrial) side of the pledgeted suture is deployed and cinched onto the annulus. After placement of the first pledget, a second wire is positioned between 2.4 and 2.8 cm from the first site, near the commissure between the posterior and anterior TV leaflets (anteroposterior position), and a second pledgeted suture is placed using the same technique. Theoretically, multiple pairs of pledgets may be implanted. If 2 pairs of pledgets are used, then the distance between the first pledget pair may be less. A dedicated plication lock device is used to bring the 2 sutures together, drawing the anteroposterior pledget toward the posteroseptal pledget. On fluoroscopic and TEE imaging, maximal plication of the tricuspid annulus is performed. A completion RCA angiogram is performed after implantation. Multiple different conformations of pledgets can be used mimicking either the classic Kay (parallel sutures) or the modified Kay (running mattress suture) procedures.
Cardioband TV Reconstruction System
The Edwards Cardioband Tricuspid Valve Reconstruction System (Edwards Lifesciences, Irvine, California) device has been successfully used to treat severe functional TR (12,13). The Cardioband Tricuspid System is a device that repairs the TV and enables individualized reduction of the annulus to a more functional state. The Cardioband transcatheter device is delivered transfemorally through the right atrium. The device is implanted on the tricuspid annulus with anchors inserted through the annulus and into the basal RV myocardium. The device thus conforms to the natural shape of the anatomy. After implantation, the device is contracted or cinched during continuous TEE guidance to reduce the septolateral diameter of the tricuspid annulus and improve leaflet coaptation under beating heart conditions with real-time confirmation of TR reduction. Cardioband offers a novel annuloplasty option for patients with significant functional TR, who are inoperable, or who are at high surgical risk. The Edwards Cardioband Tricuspid Valve Reconstruction System Early Feasibility Study (NCT03382457) has begun U.S. enrollment.
Pre-procedural preparation includes a combination of transthoracic and TEE and MSCT of the tricuspid annulus to evaluate leaflet morphology, RV function, and pulmonary artery pressure (Table 3). These imaging studies are necessary to exclude patients with annular calcification that would preclude proper placement of the Cardioband implant, and severe left heart pathologies. Transcatheter left- and right-heart catheterization is performed before the implantation as necessary based on patient history. The 25-F steerable Cardioband sheath is introduced over a Super-Stiff guidewire (Amplatzer, Boston Scientific, Marlborough, Massachusetts) into the right atrium via the right femoral vein and the IVC. The implant catheter, with the Cardioband implant mounted on the distal end, is introduced for implantation. For orientation and safety reasons, a coronary wire is placed in the RCA, which becomes also a fluoroscopic marker of the TV annulus, especially at the anterior and lateral region.
The Cardioband Tricuspid System requires an integration of fluoroscopy and TEE as intraprocedural guidance (Table 4). More recently, 3-dimensional intracardiac echocardiography has also been used for intraprocedural guidance. The fluoroscopic imaging relies on 2 projections which are patient-specific and can be easily calculated from the pre-procedural MSCT scan. The first 1 is directed along the long-axis of the RV, aiming to show a perpendicular view of the TV plane (usually a right anterior oblique view or “RAO/CRA”). This view is used to assess the device’s trajectory and the coaxiality with the tricuspid annulus. Moreover, it is used to check the proper advancement of the anchors. The simultaneous 3D TEE view helps obtain a spatial vision of the TV annulus, the leaflets, and the atrial wall.
The second fluoroscopic projection is the en face view (usually a left anterior oblique caudal view or “LAO/CAU”) of the TV, in which the valve area can be fully evaluated looking from the RV side (14). This projection is useful to navigate the catheter to the target and is the same view as the 3D echocardiography en face, seen from the RV.
Regarding 3D TEE guidance, a surgical atrial view is first used to navigate the Cardioband towards the annulus, while the anchors are deployed under simultaneous multiplane 2D view, to assess the correct distance of the hinge point and correct angle of implantation with respect to the tricuspid annulus. In selected cases with suboptimal echocardiographic window, use of intracardiac echocardiography (ICE) may also be used with TEE to visualize the annular hinge point.
The delivery catheter with the anchors is advanced from the aortic side around the anterior annulus to the posterior tricuspid annulus at the ostium of the coronary sinus. To avoid tissue injury, manipulation of the TEE probe should be kept to a minimum. Because each patient’s native anatomy is unique, 2D and 3D echocardiography may be best performed from a transesophageal or from a transgastric approach to appropriately guide the implantation of the anchors.
After the anchors are placed sequentially on the native annulus, the Cardioband Tricuspid System is progressively contracted, reducing the septolateral and the anteroposterior TV diameter. With TEE guidance, further adjustments are performed to optimize reduction in tricuspid regurgitation. Finally, a coronary angiogram is performed to check RCA patency.
Edge-to-Edge Tricuspid Valve Repair
Edge-to-edge repair has emerged as the most frequently performed interventional procedure for severe mitral regurgitation, mostly using the MitraClip device (Abbott Laboratories, Abbott Park, Illinois). Although the anatomy of the TV is much more complex, edge-to-edge repair has been successfully performed for TR reduction (15). Currently available devices require special consideration in steering to allow perpendicular access to the TV annulus and adequate grasp of 2 leaflets (16).
TEE imaging of the TV is much more demanding than the mitral side due to limited echocardiographic windows, shallow angles of insonation, and shadowing by mitral and aortic valve structures, especially when calcified or in the presence of prosthetic valves. It is therefore mandatory to ensure appropriate visibility of the TV leaflets in a careful pre-procedural TEE including a supine patient position. Patients without adequate TV visibility should not be selected for TV edge-to-edge treatment. In patients with primary TR, the underlying valve pathology must be clearly visualized during pre-procedural TEE imaging. Essential windows for procedural guidance of TV edge-to-edge repair are transgastric and deep- or mid-esophageal windows (Table 5). High-quality multiplane TEE imaging is essential for assessment of the complex leaflet anatomy and regurgitant jets, and visualization of the grasping process.
Location of the regurgitant orifice and identification of the mal-coapting leaflets should be performed using a multiwindow approach. From mid-esophageal views, one of the most useful imaging techniques is to use the 60° to 80° imaging plane which spans the septal leaflet (from posterolateral to anteromedial adjacent to the aortic valve). This view is the “commissural” view, and when used as the primary view, simultaneous multiplane imaging from the lateral TV annulus toward the aorta (a “sweep” across the tricuspid annular plane) images the coaptation site along the entire septal leaflet. Whereas each individual patient should have the location of the regurgitation clearly identified to determine the best strategy to reduce the regurgitation, Vismara et al. (17) developed an ex vivo model of functional TR and showed that grasping the septal and anterior leaflets allowed for the best post-procedural outcome, ensuring a complete re-establishment of physiological-like hemodynamics. Although the most central (i.e., mid-leaflet) grasp is ideal, some investigators have used a multidevice approach, grasping at the commissures to reduce the central orifice before attempting mid-leaflet coaptation.
For controlled advancement of the clip delivery system and navigation of the clip delivery system to the TV, a bicaval view aided by cross-plane imaging appears most helpful. Care should be taken that the tip of the clip does not perforate the interatrial septum while the clip is advanced to the TV. Once the tricuspid plane has been reached, but with the clip still in the right atrium, an imaging plane which spans the septal leaflet (from posterolateral to anteromedial adjacent to the aortic valve) is obtained using the 60° to 80° commissural view (mid- to deep-esophageal window). Using this as the primary view, simultaneous multiplane imaging from the lateral TV annulus toward the aorta (a sweep across the tricuspid annular plane) images the coaptation site along the entire septal leaflet, posterior-septal leaflet coaptation (near the lateral annulus), as well as anterior-septal coaptation (near the aorta). Simultaneous multiplane imaging allows for adjustment of the trajectory of the device to the TV, localization of the target zone from TR color flow convergence, and preliminary adjustment of clip rotation.
The next steps require a short-axis view of the TV for final adjustment of clip rotation. Because of the frequently insufficient temporal and spatial resolution of 3D imaging of the thin TV leaflets, a transgastric 2D view often results in the best views of all TV leaflets coaptation TV leaflets and is essential for a comprehensive understanding of the entire valvular apparatus (annulus, leaflets, and subvalvular tensor apparatus). It is also most valuable to localize gaps in leaflet coaptation and associated TR by correlating flow convergence and vena contracta to TV anatomy. In this view, the clip can be advanced into the RV with continuous monitoring of clip rotation; the clip advancement should be visualized by simultaneous multiplane imaging.
Grasping and securing leaflet insertion requires a mid- to deep-esophageal commissural window with the primary plane adjusted perpendicular to the clip arms showing the clip position along the commissure. The orthogonal simultaneous multiplane view aims to visualize both clip arms and leaflets concurrently during grasping. Although this is often very demanding, using the commissural view as the primary view allows easy localization of the clip along the entire septal commissure, adjusting the secondary plane slightly anterior (toward the aorta) to the clip for anteroseptal grasps, or slightly posterior (away from the aorta) for posteroseptal grasps. From this view, TR severity and inflow gradients can also be re-evaluated. After clip placement, adequate leaflet tissue grasp must be confirmed before clip release. This usually requires imaging from multiple views to ensure restriction of the leaflet motion near the clip on 2D imaging, an adequate tissue-bridge from 3D imaging, and reduction of TR by color Doppler. Three-dimensional color Doppler planimetry of the vena contracta area may be the best means of assessing reduction in TR, particularly in the setting of multiple residual jets.
The FORMA system (Edwards Lifesciences) was developed to address an important unmet clinical need of reducing TR in high-risk, symptomatic patients. The spacer acts as a surface for valve leaflet coaptation, with the aim to reduce the regurgitant orifice, and initial experience has shown the device reduces TR and is associated with significant functional improvement (8,18). The device is introduced typically from the left axillary vein via open cut-down procedure. The spacer is a foam-filled polymer balloon that passively expands via holes in the spacer shaft, and positioned across the tricuspid annulus over a rail. Two radiopaque markers help to initially position the spacer using fluoroscopy. There are 3 spacer sizes currently available (12 mm, 15 mm, and 18 mm), with a length of 42 mm. The device is fixed at the distal end in the RV myocardium by a 6-pronged nitinol anchor that is designed to minimize both the risk of penetration of the epicardial surface and the prong exposure in the RV. The device is then locked to the rail and the distal end fixed in the subclavian space.
Pre-procedural MSCT is used to evaluate vascular access anatomy and RV morphology. Intraprocedural guidance relies on fluoroscopy and 2D, as well as 3D, TEE imaging (Table 6). After left axillary vein access, a 20-F sheath (for the 12- to 15-mm spacers) or a 24-F sheath (for the 18-mm spacer) is secured in place and a right ventriculogram is performed to identify the tricuspid annular plane and RV apex. An ideal target location is identified at the RV wall perpendicular to the center of the annulus and at the septal groove of the RV. A steerable delivery catheter is advanced into the RV to deliver the rail system to this ideal location. To ensure that the device does not become entangled with chordae, a balloon on the tip of this delivery catheter is inflated before crossing the tricuspid annulus and advancing into the RV. The anchor is then deployed into the RV myocardium and adequate location and depth of implant confirmed by echocardiography; frequently simultaneous biplane imaging is helpful to image anchor location along the RV free wall, and within the septal groove. A sweep of the rail in the anterior-posterior direction is performed to confirm the absence of chordal or trabecular entanglement by pulling and pushing on the rail while imaging by echocardiography. The spacer is then tracked over the rail to the TV plane and positioned by TEE guidance to optimize TR reduction. A limited range of positions (anterior and posterior) within the short-axis plane of the annulus are possible given the access site from the superior vena cava. The septal-lateral position is typically dictated by the location of the anchor in the RV. The long-axis position of the spacer should allow leaflet coaptation at the mid-spacer level. The device is then locked proximally, and the excess rail length is coiled and placed within a subcutaneous pocket. The entire device is fully retrievable during all stages of the procedure, if needed, until sheath removal.
Navigate Transcatheter TV Replacement
The GATE System (NaviGate Cardiac Structures, Inc., Lake Forest, California) is composed of an atrioventricular valved stent, a delivery system, a compression loading system, and an introducer sheath. The valve stent is nitinol alloy with a conical shape (Table 1) and is available in 4 sizes (40- to 52-mm diameter) intended for native tissue tricuspid annular diameters of 36 to 52 mm. Twelve RV tines grasp the tricuspid leaflets from the RV side. There are 12 right atrial (RA) winglets perpendicular to the conical stent and covered by a microfiber polyester cloth designed to provide a seal. The 3 leaflets and the skirt are made of treated equine pericardium. The delivery system consists of a tip-deflecting catheter designed to go through a 42-F introducer sheath. More than 16 GATE valves have been implanted in inoperable severe, symptomatic TR patients on a compassionate-use basis. Most of these have been implanted via the transatrial route.
Sizing of the device may be performed using pre-procedural computed tomography (CT) or 3D TEE. Given the limited number of implantations, a precise sizing algorithm has not been developed; however, as little as 2% oversizing may be sufficient. A planar cross-sectional area is measured in early systole and mid-diastole as previously described (19). Although minimum and maximum diameters are recorded, the sizing is typically based on the area-derived average diameter. An RCA angiography and placement of a coronary guidewire is performed to help define the tricuspid annular plane fluoroscopically.
A minimally invasive right thoracotomy is performed in the predetermined location by CT and the atriotomy site and device trajectory perpendicular to the annular plane is confirmed using TEE imaging (Table 7). After the RA puncture is performed, a wire and pigtail are positioned across the annulus and a stiff wire is then introduced over the pigtail catheter and positioned in the RV apex. Wire positioning is confirmed by both fluoroscopy and TEE. The introducer sheath is then positioned with the tip 2 to 3 cm into the RA, and under TEE guidance the delivery system is inserted into the RA and centered in the annulus with shaft perpendicular to the annular plane.
Once the delivery system is centered and advanced across the tricuspid annulus, the valve capsule is slowly withdrawn exposing the ventricular tines of the valve. The partially unsheathed valve is then positioned with the distal end just below the leaflet tips, imaging leaflet engagement between the body of the valve and the tines. At this point, the atrial brim is still restrained and some repositioning (either ventricular or atrial) is possible to ensure that the proximal edge of the device is within the atrium, but ventricular tines remain below the annulus and leaflets before deploying the atrial end. Once the atrial brim is deployed, the delivery system is carefully withdrawn and the atriotomy and right thoracotomy closed. Final imaging of the valve position, shape, and function is performed using both fluoroscopy and TEE.
ViV Transcatheter TV Replacement
Reoperative TV replacement is known to be associated with very high operative risk (20,21). Following the demonstration of the feasibility of ViV transcatheter aortic and pulmonic valve replacement (22–25), ViV transcatheter tricuspid valve replacement was investigated as a technique to avoid or delay the need for reoperation for bioprosthetic TV failure. The first reported transcatheter TV replacement was performed with a balloon-expandable Sapien valve (Edwards Lifesciences) implanted through internal jugular venous access (26).
The largest series of ViV transcatheter TV replacement to date was published by McElhinney et al. (27) from the Valve-in-Valve International Database (VIVID) registry. This series included 152 patients with a variety of types of failing bioprosthetic TVs who underwent ViV transcatheter TV replacement. The mode of failure was predominantly regurgitation in 24% of patients, stenosis in 29%, and mixed in 47%. Transcatheter TV replacement was successful in 99% of cases and was performed with the Melody valve in 62% and with the Sapien family of valves in 38%. Transcatheter TV replacement led to significant improvements in transvalvular gradients, tricuspid regurgitation grade, and symptomatology. During a median follow-up of more than 13 months, 22 patients died and 10 TV re-interventions were performed. These results show the feasibility, clinical use, and midterm durability of ViV transcatheter TV replacement.
The evaluation of patients for ViV transcatheter TV replacement relies heavily on imaging, beginning with transthoracic echocardiography and progressing to TEE or other imaging modalities when necessary. Echocardiography is the gold standard for assessing the severity of bioprosthetic tricuspid stenosis and regurgitation. In patients with significant regurgitation, echocardiographic imaging must be of sufficient quality to rule out paravalvular regurgitation, which may require alternative treatment. Echocardiography may also be useful to exclude thrombus, vegetation, or other sequelae of endocarditis, which may also have an impact on therapeutic decisions. In patients who are considered for a ViV procedure, it is critically important to establish the size of the existing prosthesis to guide the choice of transcatheter valve. Although this information may be obtained in some cases from medical records or manufacturer records, it should be verified by echocardiography or other imaging studies.
Intraprocedure imaging for ViV transcatheter TV replacement typically consists of fluoroscopy and echocardiography (Table 8), which may be either transthoracic or transesophageal, depending on the case. A critically important step of the ViV procedure is the identification of the annular plane and selection of an appropriate fluoroscopic projection for transcatheter valve deployment. In the majority of cases, this can be achieved by aligning the radiopaque elements of the bioprosthetic valve, although RV angiography may be necessary in some cases. It is also important to observe the angle of the annular plane with respect to the planned access route, as this may have an impact on the ability to achieve coaxial positioning of the transcatheter valve.
Once the annular plane is identified, the degenerated bioprosthetic valve is crossed and a stiff wire is positioned in the RV or the pulmonary artery. The location of the distal wire should be selected so as to be as coaxial as possible to the prosthetic valve and to provide adequate support to advance the transcatheter valve delivery system. The transcatheter valve is then advanced across the bioprosthetic valve, positioned, and deployed. Although this is typically performed under fluoroscopic guidance, echocardiography may also be useful in many cases. Rapid pacing is not always required, but can be achieved with a coronary sinus lead or LV wire when desired. After deployment, echocardiography and/or right ventriculography should be performed to verify adequate positioning and to evaluate transvalvular gradients and regurgitation.
Multiple transcatheter devices for the treatment of function TR are currently under investigation. This review describes the intraprocedural imaging requirements for a representative sample of these devices to exemplify some of the imaging successes and challenges in this field. As new devices and new imaging tools are developed, intraprocedural imaging protocols will continue to evolve.
Dr. Hahn is the principal investigator for the SCOUT trial for which she receives no compensation; the Chief Scientific Officer for the Echocardiography Core Laboratory at the Cardiovascular Research Foundation for which she receives no direct industry compensation; and has received personal fees from Abbott Vascular, Boston Scientific, Bayliss, Navigate, Philips Healthcare, and Siemens Healthineers. Dr. Nabauer has received personal fees from Abbott Vascular. Dr. Nazif has received personal fees from Edwards Lifesciences, Boston Scientific, and Medtronic. Dr. Hausleiter has received personal fees from Abbott Vascular and Edwards Lifesciences. Dr. Taramasso has received personal fees from Abbott and 4Tech. Dr. Kodali has received personal fees from Duna Biotech, Thubrikar Aortic Valve Inc., Claret Medical, Meril Lifesciences, and Abbott. Dr. Bapat has received personal fees from Medtronic and Edwards Lifesciences. Dr. Maisano has received grants and personal fees from Abbott, Edwards Lifesciences, Medtronic, and Boston Scientific; and is a cofounder of 4Tech. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Abbreviations and Acronyms
- clip delivery system
- multislice computed tomography
- right atrial
- right ventricular
- transesophageal echocardiography
- tricuspid regurgitation
- tricuspid valve
- Received June 12, 2018.
- Revision received July 24, 2018.
- Accepted July 25, 2018.
- 2019 American College of Cardiology Foundation
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