How to overcome imaging challenges during tricuspid valve procedures
While tricuspid transcatheter edge-to-edge repair (TEER) and transcatheter tricuspid valve replacement (TTVR) have proven effective in treating tricuspid regurgitation patients, the crucial echocardiography imaging required to guide the delivery of these devices has proven to be much more difficult than with other valve positions. This is due to the anatomy limiting the echo imaging windows available for the tricuspid valve using a transesophageal echo (TEE). This has given rise to wider use of intracardiac echo (ICE) during these procedures.
Gilbert H. Tang, MD, professor in the department of cardiovascular surgery at the Icahn School of Medicine and surgical director of the structural heart program at the Mount Sinai Health System, talked to Cardiovascular Business about these limitations and shared some helpful recommendations at TCT 2024.
"The mitral valve is different from the tricuspid valve, particularly from the imaging standpoint. When we do the TEE, the esophagus is right behind the left heart. So it's much closer to the mitral valve than the tricuspid valve, which is on the other side," Tang explained.
To help streamline the procedure and make it more efficient and safer, he said 3D intracardiac echo is now widely used during these tricuspid procedures in addition to the TEE.
"Now you have two cameras simultaneously looking at the structure and the tricuspid valve to make sure we can put the clip on safely and securely. So now this is a game changer and, I think, a win for the patient. And we now actually expanded use of this imaging technology to transcatheter replacement valve technologies as well," he said.
Tang said another reason why the tricuspid valve can be difficult to image is that a lot of these patients have previous aortic valve replacement and mitral valve repair or replacement. These structures can shadow the tricuspid leaflets, which are thinner, so it is not as easily seen compared to the mitral valve leaflets. He added that many of these patients also have pacemaker leads that also create shadowing of the tricuspid structure.
ICE enables the operator to directly control the view of the catheter in the cath lab, but he said having an echocardiographer present for the procedure can be very helpful.
Dave Fornell has covered healthcare for more than 17 years, with a focus in cardiology and radiology. Fornell is a 5-time winner of a Jesse H. Neal Award, the most prestigious editorial honors in the field of specialized journalism. The wins included best technical content, best use of social media and best COVID-19 coverage. Fornell was also a three-time Neal finalist for best range of work by a single author. He produces more than 100 editorial videos each year, most of them interviews with key opinion leaders in medicine. He also writes technical articles, covers key trends, conducts video hospital site visits, and is very involved with social media. E-mail: dfornell@innovatehealthcare.com