Transcatheter Tricuspid Valve Therapy: From Anatomy to Intervention

Abstract

Nowadays, severe symptomatic tricuspid regurgitation (TR) affects millions of persons worldwide. However, the benefit of surgical correction of isolated secondary TR remains controversial because of the increased risk of periprocedural mortality and morbidity. In recent years, novel transcatheter tricuspid valve interventions (TTVI) were developed to treat TR, so that TTVI is currently considered in symptomatic, inoperable, anatomically eligible patients. TTVI can be divided into these five domains: edge-to-edge leaflet repair, tricuspid annuloplasty, caval implants, spacer, and total valve replacement. Each transcatheter intervention needs specific imaging protocols for assessing the anatomical feasibility and consequentially predicting the procedural success. This review summarizes the available multimodality imaging tools for screening patients with TR, and identifies anatomical characteristics to choose the best option for the patient.

Novel Computed Tomography Variables for Assessing Tricuspid Valve Morphology: Results from the TRIMA (Tricuspid Regurgitation IMAging) Study

“…Starting from their peculiar anatomical finding, the identification of commissures is the critical point for assessing these variables. The commissures are supported by fan-shaped chords and do not open directly into the annulus, but a few millimeters of the leaflet tissue remain, similar to small scallops [ 7 , 18 ]. Precisely, the AS commissure is placed anteriorly, just below the first right coronary tract and the anterior aortic valve cusp.…”

“…Using the multiplanar reconstruction, it is possible to obtain additional planes parallel to the TV for optimizing the visualization of the tricuspid leaflets, the mode of coaptation, and the grade of leaflet tethering [ 7 , 8 , 20 ]. According to the geometrical differences between atrial and ventricular functional TR, a significant correlation occurred between the degree of tethering of all leaflets and AROA, but no relationship existed between the degree of tethering and annulus area.…”

“…Anatomic knowledge of the tricuspid valve (TV) is the first step in the diagnostic algorithm of patients with tricuspid regurgitation (TR) who are candidates for transcatheter tricuspid valve intervention (TTVI) [ 1 , 2 , 3 , 4 , 5 , 6 , 7 ]. Whereas anatomical information has been historically derived from cadaveric specimens or openly, non-invasive imaging techniques now provide a complete understanding of the anatomy of the cardiac structures.…”

“…However, tailored 3D echocardiography software that accounts for the nonplanarity of the TV annulus is potentially a very reliable method of assessing TV geometry and dynamics because of the high temporal resolution of echocardiography [ 8 ]. Nevertheless, the anatomic changes of TV and the remodeling of the right chambers in patients with TR are best assessed with computed tomography (CT) imaging, owing to the acquisition of 3D data with a high spatial resolution [ 1 , 2 , 3 , 4 , 5 , 6 , 7 , 8 , 9 , 10 , 11 , 12 ]. CT imaging can shed light on the underlying mechanism of TR, defining the anatomical suitability for current transcatheter technologies, and planning TV intervention.…”

Funktionelle Trikuspidalklappeninsuffizienz – Klinische und echokardiografische Parameter für die Auswahl von Patient und Verfahren

“…Durch Bewegen des Cursors in der linken Ebene von anterior nach posterior ist eine detaillierte Beurteilung der Klappenmorphologie von antero-septal bis postero-septal möglich. Ein kleiner Koaptationsdefekt ist mit (*) gekennzeichnet.Zusammenfassend sind Patienten mit führend kommissuralen (insbesondere anteroseptalen) Jet-Ursprüngen, Koaptationsdefekten < 7 mm und wenig ausgeprägter Zügelung der Segel sowie strukturell unauffälligen Segeln und Segelrändern gute Kandidaten für eine segelbasierte (Edge-to-Edge) Therapie, während Patienten mit führend atrial bedingter Anulusdilatation, zentralem Jet und größeren Koaptationsdefekten geeignet sind für eine direkte Anuloplastie[10,11]. Innerhalb dieser Ausprägungen gibt es Patienten, die echokardiografisch für beide Prozeduren geeignet sind.…”