A Novel Hybrid Imaging Approach for Guidance of Percutaneous Transcatheter Tricuspid Valve Edge-to-Edge Repair

Abstract

Transesophageal echocardiography (TEE) is the gold standard imaging modality for transcatheter tricuspid valve edge-to-edge repair (TTVr). In patients with a TEE contraindication, intracardiac echocardiography (ICE) has a potential advantage of providing excellent visualization of the tricuspid anatomy for TTVr.1Ren J.F. Callans D.J. Marchlinksi F.E. Tricuspid regurgitation severity associated with positioning of the RV lead or other etiology assessed by intracardiac echocardiography.JACC Cardiovasc Imaging. 2014; 7: 1285-1286Crossref PubMed Scopus (10) Google Scholar,2Ren J.F. Callans D.J. Marchilinksi F.E. A simplified quantitative evaluation of right ventricular anatomy and function by intracardiac echocardiography.JACC Heart Failure. 2014; 2: 198-199Crossref PubMed Scopus (6) Google Scholar While there is literature supporting the use of four-dimensional ICE to guide TTVr,3Tang G.H.L. Yakubov S.J. Sanchez Soto C.E. 4-Dimensional intracardiac echocardiography in transcatheter tricuspid valve repair with the MitraClip system.JACC Cardiovasc Imaging. 2020; 13: 1591-1600Crossref PubMed Scopus (6) Google Scholar the device is currently on recall by the Food and Drug Administration. We present the first reported case of two-dimensional (2D) ICE supplemented with 2D and three-dimensional (3D) transthoracic echocardiography (TTE) for procedural guidance of TTVr using the MitraClip G4 device (Abbott Structural Heart, Santa Clara, CA; Figure 1) in an elderly patient with refractory right heart failure and an absolute contraindication to TEE due to a bleeding esophageal polyp. Transthoracic echocardiography demonstrated a normal left ventricular ejection fraction (67%). There was mild to moderate mitral regurgitation, severe left atrial dilatation, severe right ventricular dilation and dysfunction, severe right atrial dilation, and severe functional tricuspid regurgitation (TR). The TTVr procedure was performed under general anesthesia. The right femoral vein was accessed, and a MitraClip XTW guide catheter was advanced into the right atrium (RA). For imaging guidance, the 2D ICE catheter (6.0 MHz, AcuNav, Siemens, Mountain View, CA) was introduced into the RA via the left femoral vein. From the mid and lower RA, the RA, tricuspid valve, and right ventricle were imaged. Standard and off-axis TTE subcostal imaging windows were concurrently used to guide the clip positioning and deployment (Figure 1). A single G4 XTW MitraClip was deployed following approximation of the anterior and septal tricuspid leaflets and formation of a double orifice. For guidance during the TTVr procedure, 3D and biplane TTE imaging provided additional information beyond that obtained from ICE by enabling, first, further evaluation of tricuspid valve leaflet anatomy and location of the coaptation defect between the anterior and septal leaflets; second, confirmation of clip position and orientation and that the clip arm alignment was perpendicular to the coaptation gap; and third, corroboration that the clip grasped the anterior and septal leaflets in the desired location and a double orifice was created. Transthoracic echocardiography imaging revealed a significant reduction in TR severity to mild-moderate and the transtricuspid valve mean gradient was 1 mm Hg. The patient remained hemodynamically stable throughout the procedure and was discharged with no complications 48 hours after the procedure. A hybrid approach of using 2D ICE and 2D/3D TTE has potential utility for imaging guidance of TTVr in patients with absolute TEE contraindication and when four-dimensional ICE is not available. More experience is needed to demonstrate the feasibility of this imaging approach for TTVr.