The evolving role of multi-modality imaging in transcatheter tricuspid valve interventions

Abstract

Tricuspid valve pathophysiology is not well-understood. Emergence of novel transcatheter tricuspid therapies has fueled the requirements for improved imaging visualization techniques and interventional imaging physician skillsets in guiding these complex transcatheter procedures. There is growing understanding on the clinical significance of tricuspid regurgitation which expanded the interest for percutaneous tricuspid valve interventions. The present review concentrates on three essential aspects of tricuspid valve pathophysiology: anatomical considerations for tricuspid interventions, optimal timing of tricuspid interventions by imaging guidance, and the role of interventional imaging physicians’ skillset and knowledge in this field.

Advances in Imaging for Tricuspid Transcatheter Edge-to-Edge Repair: Lessons Learned and Future Perspectives

“…Although the relevance of cardiac computed tomography (CCT) imaging in patient screening and the pre-procedural planning of transcatheter TV treatments is less well established compared to echocardiography [29], it has high spatial resolution and offers the potential for detailed anatomic assessment, which can be critical to minimize procedural complications and to optimize results [30]. CCT is fundamental for transcatheter TV annuloplasty and valve replacement procedures, but it is not required for T-TEER [31,32]. CCT may overcome many of the limitations of 2D echocardiography by providing excellent anatomical and functional analysis of the TV apparatus, as well as its relation to the nearby structures.…”

“…In patients with pacemaker/ICD leads that are not MRI compatible, CCT represents a useful alternative for right-chamber evaluation. CCT can also evaluate the interaction of the TV leaflets with eventual pacemaker/ICD leads when they are not clear on echocardiography [31].…”

“…Fusion imaging systems combine CCT, CMR, or echocardiographic images (from TEE or ICE) with fluoroscopy, creating a multi-modalities image overlay on a single screen [31] that overcomes these limitations [17] and provides better spatial orientation, with faster and safer catheter manipulation and more accurate device orientation.…”

“…Static fusion imaging combines 3D datasets acquired prior to the procedure (generally from CCT, but it is possible also from CMR) with real-time intraprocedural fluoroscopy, showing anatomical structures not usually seen by fluoroscopy alone; its main limitations are misalignment with fluoroscopy due to registration errors, patient position changes and motion due to cardiorespiratory movements, and intracardiac catheter manipulation, but also changes in loading conditions between pre-procedural and intra-procedural time. Dynamic fusion imaging combines real-time acquired 3D echo and fluoroscopy data by co-registration of the echocardiography probe on the X-ray image, which provides greater accuracy since it crops soft tissue details that are not relevant for the procedure, adjusts overlay translucency to prevent fluoroscopy obscuration, and places persistent anatomic reference markers in the fluoroscopic space [31,64]. When the fluoroscopy C-arm moves, the 3D TEE image is automatically relocated based on the new X-ray projection (image-based tracking) [65].…”

“…When the fluoroscopy C-arm moves, the 3D TEE image is automatically relocated based on the new X-ray projection (image-based tracking) [65]. A limitation of the current fusion system technology is the color volume overlay on the fluoroscopic monitors [31].…”