Step by Step Imaging Guided

Approach for Tricuspid TEER:

What are the tips and tricks?
Rhonda Miyasaka, MD
Staff Cardiologist
Section of Cardiovascular Imaging
Cleveland Clinic
Tricuspid valve headlines

Mind the (huge coaptation) gap!

 TV TEER: not just a mitraclip in the TV position!
Anatomic variability

Crazy chords Crazy leads Crazy large gaps

But the same basic approach to evaluation for edge to edge repair is the same. Find the regurgitant origin and evaluate grasping views.
TV imaging can be challenging.
Multimodality imaging is key: know your toolbox

Echocardiography (TTE, TEE, ICE) CT MRI

What’s new in echo: 3D rendering techniques

Add a lightsource Tip: don’t forget about TTE.

for improved depth These are 3D TTE images!
perception

Increase transparency AV AV
AV AV to see color origin(s)
Vs

TR across ant-post coaptation line Focal TR origin posteriorly

Intracardiac Echo
3D ICE
2D ICE Biplane ICE
3D MPR: detailed analysis of TV anatomy and TR origin

Septal-lateral Anterior-posterior Septal-lateral Anterior-posterior

AV AV

AV AV

Tip: MPR is intimidating at first. But once you’re used to it, MPR simplifies imaging and streamlines communication.
 3D imaging is a universal language- easily move between imaging windows and modalities
TTE TEE ICE
Parasternal Apical ME Gastric

2D

TTE TEE ICE

3D Long axis Long axis Long axis Short axis Long axis
Long axis Long axis

3D

Long axis Short axis Short axis 3D

Short axis 3D Long axis 3D

3D MPR Formula: Short axis + 2 Long axis + 3D en face

Tip: Optimize 2D image quality to optimize 3D image quality
Mid esophageal fellow Deep esophageal fellow Deep esophageal staff
Tip: try all available imaging windows and the choose the
window with the best 2D image quality
Mid esophageal Deep esophageal Gastric Deep gastric

Choose the imaging window that offers the best 2D imaging quality.
 TV preprocedural imaging
Key 2D and 3D views to understand origin and mechanism
 Basic 2D evaluation

Evaluating the TV in 2D assumes a “normal” three leaflet valve and “normal” position of the heart relative to the esophagus
 Biplane TV imaging: Understand the TV “commissural” view
(Lays out the valve anterior-posterior, ie where should the clip go)

Septal leaflet out of plane Septal leaflet

AV AV AV

Posterior leaflet Anterior leaflet Posterior leaflet Anterior leaflet

Biplane sweep anterior to posterior
Posterior Anterior Septal Lateral

AV
Move Move
biplane biplane
posterior anterior
Biplane imaging doesn’t always give us the views we need
Use MPR to similar a specific TV grasping plane

You can then evaluate grasping conditions in this plane

Leaflet length, coaptation gap, subvalvular apparatus, leads
Evaluate grasping planes through the TR origin

TR origin is broad, spans anterior to posterior

 Sweep grasping plane to evaluate TR and
potential grasping planes anterior to posterior
Sept-ant commissural Sept-ant central Sept-post central Sept-post commissural

You can evaluate leaflet length, tethering, chords in each of these potential grasping planes
TV TEER: Preprocedural evaluation checklist
In potential grasping views, understand these specific valve characteristics

Leaflet size Leaflet Coaptation gap Subvalvular Device leads

• Is there restriction • Can the apparatus • Will device
enough • Can we scoop device bridge • Will the leads
leaflet for under the the gap chords interfere with
adequate leaflet to between the prevent grasping or
leaflet grasp? leaflets? leaflet imaging?
insertion? insertion?
 Leaflet Coaptation Subvalvular Device
Leaflet size
restriction gap apparatus leads

1. Leaflet size/length

8 mm

16 mm
 Leaflet Size: circumferential size may affect how many devices can be placed

Circumferential size: How much territory is there for multiple devices? How wide are the devices?

MitraClip G4
 Leaflet Coaptation Subvalvular Device
Leaflet size Imaging
restriction gap apparatus leads

Leaflet restriction in the grasping plane

Move the grasping plane more central

Short, restricted leaflet Longer, less restricted leaflet

 Leaflet Coaptation Subvalvular Device
Leaflet size
restriction gap apparatus leads

3. Coaptation gap
Reasonable gap: 5 mm
Huge gap, not a clip candidate

SL gap 5 mm
 Leaflet Coaptation Subvalvular Device
Leaflet size
restriction gap apparatus leads

Subvalvular apparatus

3D Ventricular View
RVOT
Anterior

Septal
Septal-posterior: chords

Septal-anterior: chords
Posterior

Septal-lateral: chords
Poor esophageal imaging, so entire case guided with 3D gastric views.
And yes, the chords were problematic.

Anterior chords prevent insertion Septal chords prevent insertion Finally got both

Final Result
 Leaflet Coaptation Subvalvular Device
Leaflet size
restriction gap apparatus leads

Will the lead interfere with grasping?

5. Device leads Is the lead present in the grasping plane?

No septal leaflet territory without a lead

Both pacemaker leads

adhered to the septal
leaflet
Now that we know how to evaluate a TV for
TEER, let’s do a case.
68 yo woman with marfan s/p two previous open heart surgeries,
chronic afib, now with severe TR, dyspnea and LE swelling.
3D TTE

RVOT RVOT

Septal-anterior Septal-anterior
Preprocedure TEE

Septal-anterior Septal-anterior
Clip alignment in RA
Septal-lateral Anterior-posterior
Position/trajectory Position/trajectory
Grasping
? Anterior leaflet insertion  3D ICE
We have leaflet, but how much?
Optimize anterior leaflet with 3D ICE
Final result
Summary
• Tricuspid TEER is not simply a MitraClip in the TV position
• Be aware of additional challenges both from an anatomic and an imaging
perspective
• TV imaging is multimodality: TTE, TEE, ICE
• 3D imaging bridges the gap to simplify procedural imaging