Recommended Standards for the Performance of Transesophageal Echocardiographic Screening for Structural Heart Intervention: From the American Society of Echocardiography

External validation of CLOTS-AF score in patients with atrial fibrillation undergoing transesophageal echocardiography

BACKGROUND

Predicting thromboembolic events caused by left atrial appendage thrombosis (LAAT) is crucial since it is the most concerning complication of nonvalvular atrial fibrillation (NVAF).

OBJECTIVE

The objective of this study was to establish the predictive effectiveness of a novel scoring system known as the CLOTS-AF score in identifying the existence of thrombus using transesophageal echocardiography (TEE) in patients with NVAF and to compare it with the CHA2DS2-VASc score.

METHODS

This study was conducted retrospectively with 668 NVAF patients who underwent TEE in a single centre. The patients were categorized into two categories based on the presence or absence of LAAT on TEE. The CLOTS-AF score was computed for all patients, which was then compared to the CHA2DS2-VASc score.

RESULTS

Thrombus was detected in the left atrial appendage (LAA) of 114 (17%) individuals. The study revealed that the thrombus (+) group had substantially higher CHA2DS2-VASc scores and CLOTS-AF scores (3 (2-4); 4 (3-6), p < .001), respectively. Furthermore, the CLOTS-AF score was shown to be a better predictor of LAAT than the CHA2DS2-VASc score (AUC: 0.70 vs. AUC: 0.61, p < .001).

CONCLUSIONS

This study could validate the CLOTS-AF score in an external cohort by demonstrating its significant predictive power and underscoring its vital role in clinical practice.

Advanced Echocardiographic Guidance for Transcatheter Tricuspid Edge-To-Edge Repair

Echocardiography, in all its forms (transthoracic echocardiography [TTE], transesophageal echocardiography [TEE], and intracardiac echocardiography [ICE]), is pivotal for the evaluation, guidance, and follow-up of transcatheter tricuspid edge-to-edge repair (TV-TEER) therapies. Although two-dimensional (2D) echocardiography remains essential, three-dimensional (3D) echo with multiplanar reconstruction (MPR) has revolutionized the field of structural imaging. In addition, the advent of 3D ICE has added an important modality to the imaging toolbox, particularly helpful when intraprocedural TEE images are challenging. In this review, we provide a detailed, step-by-step approach for advanced echocardiographic guidance of TV-TEER using 3D MPR.

Imaging assessment after percutaneous left atrial appendage closure: from immediate to long-term follow-up

Growing evidence has demonstrated the clinical benefit of percutaneous left atrial appendage closure (LAAC) in patients with atrial fibrillation. Although procedural complication rates have declined with increasing experience, post-procedural device-related complications persist, impacting prognosis and reducing the long-term benefits of the procedure. Given the potential impact of these complications, surveillance imaging after LAAC is mandatory. Currently, different imaging modalities offer unique advantages to manage these complications which warrant a combined approach to optimize both short- and long-term follow-up. The aims of this review are to explore the distinct characteristics of each imaging modality, highlighting the primary findings to be assessed during follow-up imaging. Additionally, we propose an optimized clinical imaging surveillance roadmap from discharge to long-term follow-up.

Left atrial appendage function by strain and structure is associated with thromboembolic risk in patients with cryptogenic stroke and TIA

BACKGROUND

We investigated the impact of left atrial appendage (LAA) function by LAA strain, LAA morphology and subclinical atrial fibrillation (AF) on LAA thrombus presence and thromboembolic risk conditions (TRC) in patients with cryptogenic stroke and transient ischaemic attack (TIA).

METHODS

185 patients (mean age 68±13 years, 33% female) were included in this prospective cohort study and underwent clinical evaluation, comprehensive transthoracic and transoesophageal echocardiography shortly after index event. LAA function and morphology were evaluated by monoplane/multiplane/speckle tracking strain and three-dimensional echocardiography. Combination of LAA thrombus and/or spontaneous echo contrast (SEC) was defined as TRC. An insertable cardiac monitor was implanted in all patients to detect subclinical AF.

RESULTS

LAA function by novel LAA strain and LAA chicken wing were independent predictors of LAA thrombus (OR 0.9 (95% CI 0.8 to 0.95), p<0.01 and OR 2.5 (95% CI 1.1 to 5.8), p=0.04, respectively). LAA chicken wing and multilobate LAA were independent predictors of TRC (OR 2.3 (95% CI 1.2 to 4.5), p=0.01 and OR 2.2 (95% CI 1.2 to 4.2), p=0.02, respectively).LAA morphology was characterised as chicken wing in 79 (43%), windsock in 64 (34%), cactus in 35 (19%), cauliflower in 7 (4%) and multilobate LAA in 115 (62%) patients. LAA thrombus was found in 29 (16%), TRC in 123 (67%) and subclinical AF in 60 (32%) patients. Duration of subclinical AF >6 hours was associated with SEC and recurrent stroke and TIA.

CONCLUSION

LAA function by novel LAA strain and LAA structure are independently associated with LAA thrombus and TRC in patients with cryptogenic stroke and TIA.

TRIAL REGISTRATION NUMBER

NCT02725944.

Low-pressure tamponade due to hemothorax after transcatheter edge-to-edge repair of the mitral valve

BACKGROUND

The use of percutaneous transcatheter edge-to-edge repair (TEER) for mitral regurgitation (MR) has increased, including an increased application to older, frailer, and higher risk patients.

CASE SUMMARY

A 74 year-old woman with severe MR, a left ventricular ejection fraction of 45%, and a small circumferential pericardial effusion underwent TEER of the mitral valve. After the placement of two MitraClips, the MR was assessed as mild to moderate. Within 10-20 minutes after the completion of the case, the patient was dyspneic and hypotensive despite volume resuscitation. Point-of-care ultrasound (POCUS) showed no changes in cardiac contractility, valve function, or the pericardial space. The right heart chambers appeared small with right atrial (RA) diastolic collapse. There was no evidence of venous congestion. Further exam showed a large right pleural fluid collection. Given the clinical scenario of dyspnea, hypotension, and diastolic RA collapse, low-pressure tamponade was suspected. A thoracentesis expelled 1200 mL of blood with immediate hemodynamic improvement. The patient made an uneventful recovery.

CONCLUSION

The application of POCUS is crucial for detecting, diagnosing, and properly managing cardiac dysfunction and procedural complications associated with TEER. While tamponade is classically associated with a pericardial effusion and vena caval plethora, their absence does not dismiss the suspicion or diagnosis of tamponade. This case highlights the value of POCUS in assessing low-pressure tamponade caused by a large, pressurized pleural effusion. Clinical suspicion, supported by POCUS findings, was confirmed by a thoracentesis that resulted in immediate hemodynamic improvement.

Echocardiographic Screening for Transcatheter Edge-to-Edge Mitral Valve Repair: Correlation Between Transthoracic and Transesophageal Assessment

BACKGROUND

In patients with significant mitral regurgitation (MR) undergoing transcatheter edge-to-edge repair (M-TEER), assessment of mitral valve (MV) anatomy is essential. While transthoracic echocardiography (TTE) is the initial diagnostic tool, transesophageal echocardiography (TOE) provides better anatomical details. The study aims to assess whether TTE is as effective as TOE in selecting patients with severe MR who are eligible for M-TEER.

METHODS

From January to December 2024, patients with severe MR eligible for TEER were enrolled at the Fondazione Monasterio Heart Hospital, Italy. They underwent a comprehensive TTE and TOE examination. Cardiologists assessed the severity of MR and valve anatomy using specific protocols. Measurements included MV area, MV gradient, posterior leaflet length, fossa ovalis high, presence of fails, clefts, and calcifications. Three levels of anatomic complexity were defined to determine eligibility for TEER.

RESULTS

The study includes 40 patients with severe MR. The correlation between TTE and TOE for key parameters was strong, with coefficients ranging from 0.734 to 0.901, indicating high agreement between the two methods. The comparison of categorical features showed high agreement between TTE and TOE in detecting critical MV conditions, with kappa values ranging from 0.717 to 0.930. The agreement for classifying patients as suitable for M-TEER was 87.5%, indicating moderate consistency between the two methods.

CONCLUSIONS

TTE may be a viable alternative to TOE for assessing MV anatomy and function before M-TEER in MR patients, especially in high-volume centers. While TTE strongly correlated with TOE for most parameters, TOE was superior for some features. Further research is needed to refine the clinical application of TTE and to define patient selection criteria for its use as the primary imaging modality for pre-procedural M-TEER screening.

Multimodality Imaging to Understand Mechanisms of Right Ventricular Disease

Right ventricular (RV) disease is commonly encountered in patients with cardiovascular conditions and is associated with adverse prognosis. The principal pathogenic mechanisms giving rise to RV pathology include RV pressure overload, RV volume overload, and RV myocardial diseases. Noninvasive cardiac imaging is commonly used to detect the conditions associated with RV disease and ultimately guide therapeutic decisions. Transthoracic echocardiogram is usually the first-line test in patients with suspected RV disease and it provides relevant information on biventricular size and function, valvular abnormalities, and cardiac hemodynamics including pulmonary pressures. Cardiac magnetic resonance imaging is considered the reference standard noninvasive imaging test for quantifying ventricular size and function and cardiac shunts and has a secondary role for assessing valvular disease when echocardiography is nondiagnostic. Cardiac magnetic resonance imaging also provides insight into RV myocardial diseases such as inflammation, infarction, and infiltration. Nuclear cardiology and cardiac computed tomography imaging can also be used to inform on specific RV disease mechanisms originating from lung disease and pulmonary vasculature disorders. In this review, we discuss the role and utility of cardiac imaging in characterizing RV mechanisms of disease and provide a suggested framework for clinicians to appropriately utilize imaging in these clinical scenarios.

Use of transoesophageal echocardiography in the pre-hospital setting to determine compression position in out of hospital cardiac arrest

BACKGROUND

A proportion of patients due to anatomical variation do not receive chest compressions over the left ventricle. Transoesophageal echocardiography (TOE) has the potential to impact survival rates by identifying the area of maximal compression (AMC), potentially improving forward flow and systemic perfusion in cardiac arrest. There is a paucity of data regarding the use of TOE during out of hospital cardiac arrest (OHCA) in the pre-hospital setting, with most data coming from studies performed in hospital. We therefore set out to retrospectively review patients who had received TOE as part of their resuscitation care by a pre-hospital medical team.

METHODS

A retrospective cohort study of OHCA patients treated by a specialist pre- hospital medical team who had received TOE as part of cardiac arrest management. Patients were identified over a 6-month period and their medical records reviewed. The primary outcome was to identify the proportion of patients in whom the AMC was not over the LV. The secondary outcomes were to describe the proportion of patients where information provided by the TOE clinically influenced patient management; to describe the temporal relationship between change in compression position and change in clinical findings including timing of ROSC or change in rhythm and to describe any associations between the AMC and physiological signs.

RESULTS

Nineteen patients were identified who had received TOE as part of cardiac arrest management over a 6 month period. Intra-arrest TOE identified 17 (89%) patients in whom compressions were not being performed over the left ventricle. Improved echocardiography evidence of left ventricular compression occurred in 13/17 (76%) patients, resulting in return of spontaneous circulation in 6 patients and change in rhythm in 10 patients. TOE was able to change management or confirm diagnosis in 17/19 (89%) patients.

CONCLUSIONS

We present a retrospective cohort study of 19 patients who received pre- hospital intra-arrest TOE. Pre-hospital intra-arrest TOE is feasible and contributed significantly to optimising compression position to increase forward flow without interrupting chest compressions. Future studies are needed to correlate clinical findings with compression position as identified on TOE.

Iatrogenic Aortic Regurgitation Caused by Arterial Cannula Tip Rotation During Cardiopulmonary Bypass: A Case Report

Iatrogenic aortic regurgitation (AR) after ventricular septal defect (VSD) closure occurs because of the distortion of the aortic valve or leaflet perforation. We presented a case of a 1-month-old child who had iatrogenic AR after VSD closure caused by the rotation of the arterial cannula tip toward the aortic valve during cardiopulmonary bypass. Transesophageal echocardiography (TEE) detected a retrograde jet flow from the arterial cannula to the aortic valve, causing eccentric AR. Our case shows a new differential diagnosis of iatrogenic AR after VSD closure and TEE's usefulness with color Doppler imaging to identify the direction of the arterial cannula tip.

Intracardiac Echocardiography to Guide Left Atrial Appendage Occlusion: An Update

The left atrial appendage occlusion (LAAO) procedure is an important intervention for stroke prevention in patients with non-valvular atrial fibrillation who cannot tolerate anticoagulation. Accurate imaging is essential to guide and ensure optimal device deployment. Transesophageal echocardiography (TEE) has traditionally been the gold standard for procedural guidance, but intracardiac echocardiography (ICE) is emerging as an alternative owing to its unique advantages. This review examines the comparative effectiveness, procedural advantages, limitations, and clinical outcomes of ICE and TEE in LAAO closure, highlighting emerging trends and implications for future clinical practice.

The Last Decade in Tricuspid Regurgitation: How Imaging Shaped a Field

The tricuspid valve has become a major focus of novel structural heart interventions, with the Conformité Européenne approval of 5 devices in Europe and the U.S. Food and Drug Administration approval of 2 devices in the United States. Multiple meta-analyses and large population-based registries have shown that although significant tricuspid regurgitation (TR) often accompanies left heart or pulmonary vascular diseases, it is associated with an increased risk of mortality and a reduced quality of life after adjusting for these comorbidities. Echocardiography remains the imaging modality of choice for diagnosing the etiology and assessing the severity of TR. However, advanced imaging techniques have played an essential role in the rapid advancement of the structural field and, in particular, transcatheter interventions for TR. Herein, we review the advances made in this field, focusing on the role that imaging has played in shaping a new field of study.

Best Practices for Imaging of Transcatheter Valve Failure: An Update From the Heart Valve Collaboratory

This updated Heart Valve Collaboratory framework addresses the growing concern for transcatheter valve failure (TVF) following transcatheter aortic valve replacement (TAVR). With the increasing volume of redo-TAV and surgical TAV explantation, there is a critical need for standardized pathways and protocols for evaluating TVF using echocardiography and cardiac computed tomography (CT) angiography. This document clarifies prior definitions of bioprosthetic valve deterioration and bioprosthetic valve failure in a practical, imaging directed context for TAVR. It discusses various imaging modalities for diagnosing TVF, including echocardiography, cardiac CT angiography, cardiac magnetic resonance, and positron emission tomography/CT. Recommendations are provided on the systematic imaging for: 1) follow-up post-TAVR; 2) procedural planning for redo-TAV; and 3) post-redo-TAV, emphasizing the importance of regular monitoring and the need for comprehensive imaging data to optimize patient outcomes in the lifetime management of aortic valve disease.

Measure Twice, Clip Once: Real-Time Assessment of Transcatheter Mitral Valve Edge-to-Edge Repair Stability

Transcatheter edge-to-edge repair of the mitral valve is a commonly accepted therapeutic alternative for a subset of patients with symptomatic mitral regurgitation. Societal guidelines focus on the screening of patients to identify suitable candidates and evaluation of postprocedural results, including residual regurgitation and transvalvular gradient. We present a case with excellent immediate reduction of mitral regurgitation by transcatheter edge-to-edge repair, but subsequent development of single leaflet detachment that may have been prevented by intraprocedural quantitative echocardiographic assessments.

State of the Art in Left Atrial Appendage Occlusion

Left atrial appendage occlusion (LAAO) has become an important therapeutic target for stroke prevention in patients with nonvalvular atrial fibrillation. Over the past 2 decades, several advancements in LAAO devices (percutaneous and surgical) have been made for stroke prevention and arrhythmia therapy. However, there are several unanswered questions regarding optimal patient selection, the preferred LAAO approach and device, the management of periprocedural and postprocedural complications, including pericardial effusion, device-related thrombus, and device leaks. This review focuses on fundamental foundational concepts in various aspects of the left atrial appendage and management strategies as they relate to current clinical needs.

Updated Review of Transcatheter Strategies and Intervention for Mitral Regurgitation

Mitral regurgitation (MR) is a prevalent valvular heart disease with significant morbidity, particularly in aging populations. Management strategies for MR have evolved from traditional open-heart surgery to innovative transcatheter approaches, addressing the limitations of surgical repair in high-risk patients. Transcatheter edge-to-edge repair, exemplified by devices such as MitraClip and PASCAL, has shown efficacy in reducing MR severity, improving functional capacity, and decreasing heart failure hospitalizations in selected patients. Advances in annuloplasty and chordal repair offer minimally invasive options with promising early outcomes. Transcatheter mitral valve replacement represents the frontier of MR treatment, addressing anatomical complexities unsuitable for repair, though complications such as left ventricular outflow tract obstruction persist. Emerging data from clinical trials underscore the importance of patient selection and a multidisciplinary heart team approach. In this review, each modality is discussed concerning its indications, procedural techniques, outcomes, and associated challenges. It highlights the transformative potential of transcatheter mitral valve interventions while emphasizing the need for ongoing innovation and research to optimize outcomes and expand therapeutic options for patients with severe MR.

Cardiovascular Syphilis

Syphilis is a disease caused by the spirochete bacterium Treponema pallidum, progressing in 4 stages: primary, secondary, latent, and tertiary syphilis. In the tertiary stage, patients may develop cardiovascular syphilis, which includes syphilitic aortitis, aortic aneurysm, aortic regurgitation, and coronary artery involvement. These cardiovascular manifestations increase morbidity and mortality during this late stage of syphilis. A recent large-scale, population-wide study has built on our knowledge of cardiovascular syphilis by identifying an increased risk for the development of acute myocardial infarction, heart failure, atrial fibrillation, ischemic stroke, hemorrhagic stroke, venous thromboembolism, and cardiovascular death in syphilis patients. This review discusses the incidence and pathophysiology of these various manifestations of cardiovascular syphilis, while also detailing the latest treatment options and the prognosis of these conditions. The clinical significance of this topic stems from the fact that the incidence of syphilis has spiked in recent years after previously reaching an all-time low in 1999. According to the Centers for Disease Control in the United States, from 2018 to 2022, the reported cases of syphilis increased by 80%. However, the incidence of cardiovascular syphilis has remained the same during this period, likely due to the efficacy of penicillin use early in the infection, preventing the progression of the disease to the tertiary stage. As a result, cardiovascular syphilis mostly remains a disease of the past, with only a few sporadic cases being reported in the literature in recent years.

Multimodality Imaging Evaluation of Diseases of the Pulmonic Valve and Right Ventricular Outflow Tract for the Adult Cardiologist

Disorders of the pulmonic valve (PV) receive considerably less attention than other forms of valvular heart disease. Due to the dramatically improved survival of children with congenital heart disease over the last 5 decades, there has been a steady increase in the prevalence of adults with congenital heart disease, which necessitates that clinicians become familiar with the anatomy and the evaluation of right ventricular outflow tract and PV anomalies. A multimodality imaging approach using echocardiography, cardiac computed tomography, and magnetic resonance imaging is essential for a comprehensive evaluation of the anatomy and function of the right ventricular outflow tract, PV, and supravalvular region. As clinical presentation is often insidious with nonspecific symptoms, yet morbidity and mortality associated with severe untreated PV disease are significant, a high index of suspicion coupled with appropriate use of imaging techniques is critical in facilitating timely diagnosis and treatment. In this review, we aim to present a comprehensive approach to the diagnosis of PV disease and associated right ventricular outflow tract or supravalvular pulmonary stenosis, including optimal use of multimodality imaging to facilitate timely diagnosis, optimize therapeutic strategies, enhance postprocedural surveillance, and ultimately improve patient outcomes.

3D transoesophageal echocardiographic assessment of acute reverse remodelling of the tricuspid annulus after transcatheter edge-to-edge repair

AIMS

Our study aims to evaluate the acute remodelling of the tricuspid valve annulus immediately after the tricuspid transcatheter edge-to-edge repair (T-TEER) by using intraprocedural transoesophageal 3D echocardiography.

METHODS AND RESULTS

We prospectively enrolled 62 consecutive symptomatic patients with at least severe tricuspid regurgitation (TR), who underwent T-TEER with the TriClip System between March 2021 and June 2024. The following parameters were assessed using a multiplanar reconstruction analysis performed off-line using a 3D data set: septal-lateral (SL) and antero-posterior (AP) annulus diameters; annulus area; annulus perimeter; and eccentricity index. The acute procedural success was achieved in 85.5%. We observed an acute reduction in SL (from a median of 43 to 38 mm, P < 0.0001), AP (from a median of 46 to 45 mm, P < 0.0001), area (from a median of 17.9 to 15.95 cm2, P < 0.0001), perimeter (from a median of 145.5 to 137 mm, P < 0.0001), and eccentricity index (from 0.92 to 0.87, P < 0.0001). The tricuspid valve (TV) annulus was progressively larger in patients with higher residual TR. Analysis of the subgroups according to procedural success showed an acute inverse remodelling of the TV annulus independent of the acute procedural success.

CONCLUSION

The TV geometry necessitates the use of 3D echocardiography for accurate assessment of annular remodelling post T-TEER. The reduction in TR grade and TV annulus dimensions begins immediately after TriClip implantation. Concurrently, the baseline TV geometry influences the procedural results.

Efficacy of transcatheter edge-to-edge repair for cardiac implantable electronic device-associated tricuspid regurgitation: insights from the TRI-SPA registry

INTRODUCTION AND OBJECTIVES

This study aimed to assess the effectiveness and clinical outcomes of tricuspid transcatheter edge-to-edge repair (T-TEER) in patients with cardiac implantable electronic devices (CIEDs).

METHODS

This subanalysis of the Transcatheter Tricuspid Valve Repair in Spain (TRI-SPA) registry included patients with at least severe tricuspid regurgitation (TR) who were treated with T-TEER between June 2020 and May 2023 in Spain. Patients with CIEDs and no or mild tricuspid lead-leaflet interaction were compared with those without CIEDs. The primary composite endpoint was all-cause mortality, heart failure-related hospitalization, and tricuspid valve reintervention at 12 months.

RESULTS

Among 310 patients (mean age 75.5±9.1 years, 70% female) with significant TR treated with T-TEER, 35 (11%) had CIEDs. Device implantation success was high in both groups (97.1% in the CIED group vs 96.4% in the non-CIED group, P=.81), with a similar rate of ≤2+ residual TR (84.9% in the CIED group vs 91.0% in the non-CIED group, P=.26). Patients with CIEDs experienced comparable rates of the primary composite endpoint to the non-CIED group (23.8% vs 19.1%, respectively, HR, 1.40; 95%CI, 0.60-3.31; P=.44), sustained successful TR reduction (δ 2+ in 55.0% vs 73.8%, P=.07), and functional improvement (NYHA class I/II 81.8% vs 79.9%, P=.79).

CONCLUSIONS

In a real-world setting, T-TEER seems to be an effective therapeutic option for selected patients with more than moderate TR and CIEDs with no or mild lead-leaflet interaction, offering comparable cardiovascular outcomes and clinical improvement to those without leads. However, the presence of CIEDs may represent an independent risk factor for TR recurrence.

The ImageGuideEcho Registry: Using Data Science to Understand and Improve Echocardiography

PURPOSE OF REVIEW

To provide a contemporary update on the American Society of Echocardiography's ImageGuideEcho Registry and present a case study of an individual institution's experience with enrollment.

RECENT FINDINGS

Technical innovation in clinical echocardiography has expanded the impact of echocardiography in cardiovascular care and provides new opportunities to leverage clinical data to inform quality improvement initiatives and research. The ImageGuideEcho Registry is the first echocardiography-specific imaging registry in the United States and provides a data infrastructure for quality improvement and multicenter research. The ImageGuideEcho Registry continues to grow, offering a window into echocardiography care across the United States in a variety of practice settings. This early experience highlights its value, opportunities, and ongoing challenges. Continued innovation, such as the addition of primary images, will further add to the substantial value of the registry.

Transcatheter Tricuspid Valve Replacement

Transcatheter tricuspid valve replacement (TTVR) has emerged as a promising intervention for the treatment of severe tricuspid regurgitation with complex valve morphology. This consensus document provides a comprehensive overview of the current state of orthotopic TTVR, focusing on patient selection, procedural details, and follow-up care. Clinical outcomes from initial studies and compassionate use cases are discussed, highlighting the effectiveness of TTVR in reducing tricuspid regurgitation, inducing reverse right ventricular remodeling, and enhancing patients' quality of life. This review paper also addresses potential complications and challenges associated with TTVR, such as new-onset conduction disturbances, bleeding complications, and afterload mismatch, and provides expert recommendations for the periprocedural management, anticoagulation strategies, and long-term follow-up. With the commercial approval of the first TTVR system in the United States and Europe, it intends to serve as a reference for clinicians and researchers involved in the evolving field of transcatheter tricuspid valve interventions.

Tricuspid Transcatheter Edge-to-Edge Repair for Severe Tricuspid Regurgitation: 1-Year Outcomes From the TRILUMINATE Randomized Cohort

BACKGROUND

Tricuspid regurgitation (TR) is a right-sided valvular disease independently associated with morbidity and mortality. The TRILUMINATE Pivotal (Clinical Trial to Evaluate Cardiovascular Outcomes In Patients Treated With the Tricuspid Valve Repair System Pivotal) is the first randomized controlled trial assessing the impact of TR reduction with tricuspid transcatheter edge-to-edge repair (T-TEER).

OBJECTIVES

Outcomes from the full randomized cohort of the TRILUMINATE Pivotal trial have not been previously reported, and the additional enrollment may further support the safety and effectiveness of T-TEER through 1 year.

METHODS

The TRILUMINATE Pivotal trial is an international randomized controlled trial of T-TEER with the TriClip device in patients with symptomatic, severe TR. Adaptive trial design allowed enrollment past the primary analysis population. The primary outcome was a hierarchical composite of all-cause mortality or tricuspid valve surgery, heart failure hospitalizations (HFHs), and quality-of-life improvement measured by Kansas City Cardiomyopathy Questionnaire (KCCQ) at 1 year.

RESULTS

Between August 21, 2019, and June 29, 2022, 572 subjects were randomized, including the primary cohort (n = 350) and subsequent enrollment (n = 222). Subjects were older (78.1 ± 7.8 years) and predominantly female (58.9%), with atrial fibrillation (87.8%) and prior HFH (23.8%). The primary endpoint was met for the full cohort (win ratio = 1.84; P < 0.0001). Freedom from all-cause mortality and tricuspid valve surgery through 12 months was 90.6% and 89.9% for the device and control groups, respectively (P = 0.82). Annualized HFH rate was comparable between device and control subjects (0.17 vs 0.20 events/patient-year; P = 0.40). A significant treatment effect was observed for change in quality of life with 52.3% of device subjects achieving a ≥15-point KCCQ score improvement (compared with 23.5% of control subjects; P < 0.0001). All secondary endpoints favored T-TEER: moderate or less TR at 30 days (88.9% vs 5.3%; P < 0.0001), KCCQ change at 1 year (13.0 ± 1.4 points vs -0.5 ± 1.4 points; P < 0.0001), and 6-minute walk distance change at 1 year (1.7 ± 7.5 m vs -27.4 ± 7.4 m; P < 0.0001). Freedom from major adverse events was 98.9% for T-TEER (vs performance goal: 90%; P < 0.0001).

CONCLUSIONS

TriClip was safe and effective in the full randomized cohort of TRILUMINATE Pivotal with significant TR reduction and improvements in 6-minute walk distance and health status. Rates of all-cause mortality or tricuspid valve surgery and HFH through 1 year were not reduced by T-TEER.

The Use of 3D-Echo in Edge-to-Edge Percutaneous Tricuspid Valve Repair

The tricuspid valve (TV) is a complex anatomical entity. As surgical treatment for isolated tricuspid regurgitation has traditionally been associated with high peri- and post-operative mortality, advances in percutaneous transcatheter techniques of repair and replacement of the TV are emerging as safe and effective alternatives. This review summarizes the current evidence on the use of three-dimensional echocardiography to assist transcatheter-edge-to-edge repair (TEER) in patients with tricuspid regurgitation.

Atrial Functional Mitral Regurgitation Subtypes Undergoing Transcatheter Edge-to-Edge Repair: Suboptimal Outcomes in Atriogenic Hamstringing

BACKGROUND

Two subtypes of atrial functional mitral regurgitation (AFMR) have been described, one is characterized by Carpentier type I and the other by Carpentier type IIIb leaflet motion.

OBJECTIVES

The authors sought to analyze echocardiographic characteristics and outcomes of AFMR subtypes undergoing mitral valve transcatheter edge-to-edge repair (M-TEER).

METHODS

Of 1,047 consecutive patients who underwent M-TEER, the authors identified those with isolated mitral annulus dilation (Carpentier I), termed AFMR-IAD, and those with atriogenic hamstringing characterized by restricted posterior mitral leaflet motion (Carpentier IIIb), termed AFMR-AH. Echocardiographic baseline characteristics and outcomes up to 1-year were analyzed.

RESULTS

A total of 128 patients (12.2%) met AFMR criteria; 75 (58.6%) were identified as AFMR-IAD and 53 (41.4%) as AFMR-AH. AFMR-AH displayed greater left atrial and left ventricular volumes, greater mitral annulus, shorter and steeper posterior mitral leaflet, and more pronounced MR (all P < 0.05). Technical success was achieved in 98.7% (AFMR-IAD) and 86.8% (AFMR-AH) of patients (P = 0.009). At discharge, device detachments were exclusively observed in AFMR-AH (10.0%). MR ≤II was achieved in 95.6% and 78.6% at 30 days (P = 0.009) and in 93.0% and 74.1% at 1 year (P = 0.038) in patients with AFMR-IAD and AFMR-AH, respectively. AFMR-AH was associated with procedural failure (OR: 1.17 [95% CI: 1.00-1.38]; P = 0.045) at 30 days (43.4% vs 24.0%; P = 0.023) and all-cause mortality (HR: 2.54 [95% CI: 1.09-5.91]; P = 0.031) at 1 year (77% vs 92%, Kaplan-Meier estimated 1-year survival; P = 0.017).

CONCLUSIONS

AFMR-AH shows worse procedural and clinical outcomes following M-TEER than AFMR-IAD. Thus, vigilance regarding this pathology is warranted and alternative mitral valve therapies might need to be considered.

Structural Heart Imaging Using 3-Dimensional Intracardiac Echocardiography: JACC: Cardiovascular Imaging Position Statement

3-dimensional (3D) intracardiac echocardiography (ICE) is emerging as a promising complement and potential alternative to transesophageal echocardiography for imaging guidance in structural heart interventions. To establish standardized practices, our multidisciplinary expert position statement serves as a comprehensive guide for the appropriate indications and utilization of 3D-ICE in various structural heart procedures. The paper covers essential aspects such as the fundamentals of 3D-ICE imaging, basic views, and workflow recommendations specifically tailored for ICE-guided structural heart procedures, such as transeptal puncture, device closure of intracardiac structures, and transcatheter mitral and tricuspid valve interventions. Current challenges, future directions, and training requirements to ensure operator proficiency are also discussed, thereby promoting the safety and efficacy of this innovative imaging modality to support expanding its future clinical applications.

Prevention of left ventricular outflow tract obstruction in transapical mitral valve replacement: the MitraCut procedure

BACKGROUND

The MitraCut procedure employs beating heart transapical (TA) cannulation and endoscopic scissors for dividing the anterior mitral leaflet (AML) to prevent left ventricular outflow tract (LVOT) obstruction in transapical transcatheter mitral valve replacement (TA-TMVR).

AIMS

We present the first multicentre experience of the MitraCut procedure prior to TA-TMVR to prevent LVOT obstruction.

METHODS

In 6 European centres, the clinical outcomes of all 13 high-risk patients who had undergone the MitraCut procedure during TA-TMVR procedures were retrospectively reviewed regarding technical success, procedural details and outcome.

RESULTS

The MitraCut procedure was successfully completed in 11 patients with 1 cutting attempt, while 2 patients had 2 cutting attempts, with an average procedure duration of 9.0±5.4 min. No patient demonstrated postoperative LVOT obstruction, and all mitral valve (MV) prostheses were competent throughout the follow-up period. However, 1 patient developed a MitraCut-related paravalvular leak (PVL; technical success rate: 12/13). The mean LVOT gradient was 3.9±4.4 mmHg directly after valve expansion and 3.6±3.1 mmHg at follow-up. In-hospital and 30-day mortality were 0%. One patient experiencing MitraCut-related PVL was successfully treated by interventional PVL closure (reintervention rate: n=1). One patient died at 47 days due to cardiac arrhythmia, unrelated to the AML-directed procedure. The mean follow-up at the time of data analysis was 52±34 days.

CONCLUSIONS

The MitraCut procedure was effective and reproducible for preventing potential LVOT obstruction in TA-TMVR patients during its initial exploration in 6 European hospitals. Considerations regarding the scissors' characteristics, their handling and cut length are mandatory for safe performance of the procedure.

Concept, Design, and Preclinical Testing of a Remote-Control Robotic System for Transesophageal Echocardiography

Background

Interventional echocardiography (IE) plays a critical role in guiding structural heart interventions. IE specialists face challenges including high radiation exposure and unfavorable ergonomics. To address these issues, a novel remote-control robotic (RCR) system for transesophageal echocardiography (TEE) control has been developed. This study aims to describe the novel RCR system and to assess its performance in bench tests and in vitro models in terms of functionality, image quality, and reproducibility.

Methods

Bench testing and in vitro testing were performed using the RCR system. All tests were performed using the GE 6VT-D TEE probe and the GE Vivid E95.

Results

Key findings include proof of concept through bench testing, remote control of all five degrees of freedom of the TEE probe, and reliable, fast, and accurate reproducibility using automated navigation. The ROB'E Base is securely attached to the operating table, optimizing the footprint in the operating room. The ROB'E Guide accurately performs the forward and backward motion of the flexible portion of the TEE probe, stabilizing the achieved positions and preventing twisting during rotation. The ROB'E RCR system can store and reproduce TEE probe positions and has demonstrated reliable and accurate automated reproducibility in both bench and in vitro tests.

Conclusions

The ROB'E RCR system for TEE overcomes the limitations of conventional IE by using a RCR approach that eliminates the need for the echocardiographer to be physically present in the operating room. Thus, it significantly reduces radiation exposure and demonstrates its capabilities to improve image quality, reproducibility, and overall safety in IE.

Transoesophageal echocardiography beyond the echo-laboratory. An expert consensus paper of the working group of echocardiography of the hellenic society of cardiology

Transoesophageal echocardiography (TOE) is a well-established and valid imaging modality, providing more accurate and of higher quality information than transthoracic echocardiography (TTE) for several specific diagnoses and recently a useful guide of an increasing number of catheter-based and surgical interventions. The present paper represents an effort by the Echocardiography Working Group (WG) of the Hellenic Society of Cardiology to state the essential steps of the TOE exam performed beyond the echo lab: a) in the operating rooms intraoperatively during either transcatheter interventions, or cardiothoracic surgery and b) in the intensive care unit for critically ill patients' monitoring. This paper includes information and tips and tricks about the pre-procedural evaluation, the procedural echocardiographic guidance, and post-procedural evaluation of the result and potential complications.

Standardized 3D Transoesophageal Echocardiography Manoeuvre for Enhanced Tenting Height Evaluation During Transcatheter Mitral Valve Edge-to-Edge Repair

Background: Transcatheter treatments for structural heart disease, including edge-to-edge mitral valve repair (mTEER), heavily rely on transoesophageal echocardiography (TOE) for pre-procedural assessment and guidance. Trans-septal puncture (TSP) is one of the first key steps of such procedures, with two-dimensional (2D) TOE often providing suboptimal imaging. Three-dimensional (3D) echocardiography could overcome the limitations of 2D TOE and improve the assessment of tenting height. Methods: This single-centre, retrospective study included 64 patients who underwent mTEER between October 2023 and April 2024. Tenting height during TSP was assessed by 2D TOE in mid-oesophageal (ME) four-chamber view and by 3D TOE after the acquisition of a 3D volume, including the interatrial septum, aortic valve, and mitral valve, and subsequent multiplanar reconstruction (MPR). A total of 100 TSP attempts with 2D and 3D TOE were evaluated. Results: Procedural success was obtained in 92.2% of cases. There was a statistically significant difference between 2D and 3D measurements (2D: 4.36 ± 0.61 cm, MPR: 4.59 ± 0.63 mm2, p < 0.001), despite good correlation (r = 0.880, p < 0.001). The difference between 2D and 3D tenting height measurements differed significantly between patients with optimal and suboptimal 2D image windows (p < 0.001). There was no significant difference in septal puncture success between optimal 2D and 3D data (p = 0.942). Conclusions: Adopting 3D TOE with multiplanar reconstruction for assessing tenting height in mTEER procedures offers significant advantages over traditional 2D TOE. Enhanced visualization, accuracy, and potential for standardization improve procedural outcomes and patient safety, making 3D TOE integration into routine practice highly beneficial and recommended.

Findings from transoesophageal echocardiographic follow-up after mitral transcatheter edge-to-edge repair

BACKGROUND

Transoesophageal echocardiography (TOE) provides accurate evaluation of mitral valve (MV) function following mitral transcatheter edge-to-edge repair (M-TEER) and may better detect complications in case of suboptimal result.

AIMS

We aimed to evaluate midterm anatomical changes and structural complications after M-TEER using TOE and investigate their association with clinical outcomes at 2 years.

METHODS

A follow-up TOE at 6 months was systematically recommended to all patients included in our institutional prospective M-TEER registry until December 2021. We assessed changes in the incidence of mitral regurgitation (MR), MV stenosis (≥5 mmHg), and partial or complete single leaflet device attachment (SLDA) between the index procedure and follow-up and evaluated MV area and annular dimensions in a subset of patients with available three-dimensional (3D) datasets. The clinical endpoint was a composite of mortality and heart failure (HF) rehospitalisation at 2 years.

RESULTS

Among the 373 patients included in the registry between February 2012 and December 2021, 128 patients (34%) underwent elective TOE at 6 months. Using TOE, severe MR was observed in 13.3% (n=17) of the patients. The number of patients with an elevated MV gradient increased from 17 (13.3%) after the procedure to 23 (18%) at 6 months, and a new partial or complete SLDA was detected in 7.8% (n=10). Based on 3D TOE measurements, significant increases in MV area, annular area, annular perimeter, and intercommissural (but not anteroposterior) diameter were observed compared to intraprocedural images. A mean MV gradient ≥5 mmHg (hazard ratio [HR] 2.30, 95% confidence interval [CI]: 1.10-4.81; p=0.023) and the presence of severe MR at 6 months (HR 3.26, 95% CI: 1.18-8.99; p=0.023) were associated with the primary endpoint, which was met in 34 (26.6%) patients at 2 years.

CONCLUSIONS

TOE follow-up allowed the detection of complications that would not be diagnosed using transthoracic echocardiography only and should therefore be used liberally in the patients presenting with a suboptimal result. A mean MV gradient ≥5 mmHg and severe MR, diagnosed at the 6-month TOE follow-up, were associated with adverse clinical outcomes.

Key Imaging Factors for Transcatheter Management of Tricuspid Regurgitation: Device and Patient Selection

The growing awareness of tricuspid regurgitation (TR) and the fast-expanding array of devices aiming to percutaneously repair or replace the tricuspid valve have underscored the central role of multi-modality imaging in comprehensively assessing the anatomical and functional characteristics of TR. Accurate phenotyping of TR, the right heart, and pulmonary vasculature via echocardiography, computed tomography, and, occasionally, cardiovascular magnetic resonance and right heart catheterization is deemed crucial in choosing the most suitable treatment strategy for each patient and achieving procedural success. In the first part of the present review, key imaging factors for patient selection will be discussed. In the ensuing sections, an overview of the most commonly used, commercially available systems for transcatheter repair/replacement will be presented, along with their respective selection criteria and information on intraprocedural imaging guidance; these are edge-to-edge repair, orthotopic and heterotopic replacement, and valve-in-valve procedures.

Whispers of the Cath lab: "Cases we would rather forget"

In the dynamic field of interventional cardiology, significant strides have been made in reducing periprocedural complications. Echocardiography, particularly transesophageal echocardiography, plays a key role in ensuring the safety and success of structural heart interventions. Its real-time imaging capabilities allow for precise monitoring of device positioning, deployment, and procedural outcomes. By adhering to established imaging protocols and acquiring standard imaging planes, periprocedural echocardiography has become an essential tool for the successful performance of many structural heart interventions. In this manuscript, we present a series of unusual yet significant complications that we encountered during structural interventional procedures in our catheter laboratory. These complications, detected through echocardiography, underscore the critical role of imaging guidance in recognizing, and addressing unforeseen challenges, such as device malposition, thrombus formation in cardiac chambers during structural heart interventions, and cardiac tamponade during transcatheter mitral valve procedures. Through these cases, we highlight the effectiveness of transesophageal echocardiography in promptly identifying complications, allowing for timely intervention and resolution.

3-Dimensional Echocardiographic Prediction of Left Ventricular Outflow Tract Area Prior to Transcatheter Mitral Valve Replacement

BACKGROUND

New postprocessing software facilitates 3-dimensional (3D) echocardiographic determination of mitral annular (MA) and neo-left ventricular outflow tract (neo-LVOT) dimensions in patients undergoing transcatheter mitral valve replacement (TMVR).

OBJECTIVES

This study aims to test the accuracy of 3D echocardiographic analysis as compared to baseline computed tomography (CT).

METHODS

A total of 105 consecutive patients who underwent TMVR at 2 tertiary care centers between October 2017 and May 2023 were retrospectively included. A virtual valve was projected in both baseline CT and 3D transesophageal echocardiography (TEE) using dedicated software. MA dimensions were measured in baseline images and neo-LVOT dimensions were measured in baseline and postprocedural images. All measurements were compared to baseline CT as a reference. The predicted neo-LVOT area was correlated with postprocedural peak LVOT gradients.

RESULTS

There was no significant bias in baseline neo-LVOT prediction between both imaging modalities. TEE significantly underestimated MA area, perimeter, and medial-lateral dimension compared to CT. Both modalities significantly underestimated the actual neo-LVOT area (mean bias pre/post TEE: 25.6 mm2, limit of agreement: -92.2 mm2 to 143.3 mm2; P < 0.001; mean bias pre/post CT: 28.3 mm2, limit of agreement: -65.8 mm2 to 122.4 mm2; P = 0.046), driven by neo-LVOT underestimation in the group treated with dedicated mitral valve bioprosthesis. Both CT- and TEE-predicted-neo-LVOT areas exhibited an inverse correlation with postprocedural LVOT gradients (r2 = 0.481; P < 0.001 for TEE and r2 = 0.401; P < 0.001 for CT).

CONCLUSIONS

TEE-derived analysis provides comparable results with CT-derived metrics in predicting the neo-LVOT area and peak gradient after TMVR.

EVOQUE Tricuspid Valve Replacement System: State-of-the-Art Screening and Intraprocedural Guidance

With the recent approval of the transcatheter EVOQUE tricuspid valve replacement system to treat severe, symptomatic tricuspid regurgitation, there is a need to define the appropriate patient population and anatomical considerations for this device. In this consensus document, the authors review these considerations, describe the procedural steps and imaging requirements to ensure technical success, and discuss management of complex intraprocedural circumstances.

Tricuspid Regurgitation Complicating Heart Failure: A Novel Clinical Entity

With the escalating incidence of heart failure, accurate diagnosis is paramount for tailored therapeutic interventions. The tricuspid valve, particularly tricuspid regurgitation, once relegated as the "forgotten valve", has gained prominence due to increasing evidence implicating severe tricuspid valve disease in the prognosis of diverse cardiovascular conditions. This review delineates recent significant advancements in imaging modalities, transcatheter interventions, and epidemiological and pathophysiological insights regarding tricuspid regurgitation complicating heart failure. A comprehensive understanding of these innovative concepts and technologies can significantly improve patient outcomes.

Cardiopulmonary Resuscitation Without Aortic Valve Compression Increases the Chances of Return of Spontaneous Circulation in Out-of-Hospital Cardiac Arrest: A Prospective Observational Cohort Study

OBJECTIVES

Following current cardiopulmonary resuscitation (CPR) guidelines, which recommend chest compressions at "the center of the chest," ~50% of patients experiencing out-of-hospital cardiac arrest (OHCA) undergo aortic valve (AV) compression, obstructing blood flow. We used resuscitative transesophageal echocardiography (TEE) to elucidate the impact of uncompressed vs. compressed AV on outcomes of adult patients experiencing OHCA.

DESIGN

Prospective observational cohort study.

SETTING

Single center.

PATIENTS

This study included adult OHCA patients undergoing resuscitative TEE in the emergency department. Patients were categorized into AV uncompressed or AV compressed groups based on TEE findings.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

The primary outcome was sustained return of spontaneous circulation (ROSC). The secondary outcomes included end-tidal co2 (Et co2 ) during CPR, any ROSC, survival to ICU and hospital discharge, post-resuscitation withdrawal, and favorable neurologic outcomes at discharge. Additional analyses on intra-arrest arterial blood pressure (ABP) were also conducted. The sample size was pre-estimated at 37 patients/group. From October 2020 to January 2023, 76 patients were enrolled, 39 and 37 in the AV uncompressed and AV compressed groups, respectively. Intergroup baseline characteristics were similar. Compared with the AV compressed group, the AV uncompressed group had a higher probability of sustained ROSC (53.8% vs. 24.3%; adjusted odds ratio [aOR], 4.72; p = 0.010), any ROSC (56.4% vs. 32.4%; aOR, 3.30; p = 0.033), and survival to ICU (33.3% vs. 8.1%; aOR, 6.74; p = 0.010), and recorded higher initial diastolic ABP (33.4 vs. 11.5 mm Hg; p = 0.002) and a larger proportion achieving diastolic ABP greater than 20 mm Hg during CPR (93.8% vs. 33.3%; p < 0.001). The Et co2 , post-resuscitation withdrawal, and survival to discharge revealed no significant intergroup differences. No patients were discharged with favorable neurologic outcomes. Uncompressed AV seemed critical for sustained ROSC across all subgroups.

CONCLUSIONS

Absence of AV compression during OHCA resuscitation is associated with an increased chance of ROSC and survival to ICU. However, its effect on long-term outcomes remains unclear.

The Year in Perioperative Echocardiography: Selected Highlights from 2023

This article is the eighth in an annual series reviewing the research highlights of the year pertaining to the subspecialty of perioperative echocardiography for the Journal of Cardiothoracic and Vascular Anesthesia. The authors thank the editor-in-chief, Dr Kaplan, and the editorial board for the opportunity to continue this series. In most cases, these will be research articles targeted at the perioperative echocardiographic diagnosis and treatment of patients after cardiothoracic surgery; but in some cases, the articles will target the use of perioperative echocardiography in general.

Prognostic impact of increase in left atrial volume following left atrial appendage closure: Insights from the OCEAN-LAAC registry

BACKGROUND

Percutaneous left atrial appendage closure (LAAC) is an effective therapy to prevent thromboembolic events among patients with atrial fibrillation (AF). However, since the left atrial appendage (LAA) contributes to left atrial volume and serves as a buffer for increasing left atrial pressure, this procedure may impair left atrium (LA) compliance, enlarge LA, and deteriorate diastolic function. In this study, we sought to investigate the change in left atrial volume index (LAVI) following LAAC and its effect on prognosis.

METHODS AND RESULTS

We analyzed 225 patients from the OCEAN-LAAC registry, an ongoing, multicenter Japanese study. Comparing LAVI measurements at baseline and 6 months after LAAC, no significant increase was observed (55.0 [44.0, 70.0] ml/m2 vs. 55.0 [42.0, 75.6] ml/m2; P = 0.31). However, some patients underwent LAVI increase. Particularly, a smaller LAVI (odds ratio [OR]: 0.98 [95 % confidence interval (CI): 0.97-0.996]) and elevated tricuspid regurgitation pressure (TRPG) at baseline (OR: 1.04 [95 % CI: 1.00 - 1.08]) were significantly related to the increase in LAVI at 6-month follow-up. In addition, a 5 ml/m2 increase in LAVI was significantly associated with subsequent heart failure hospitalization (HFH) (hazard ratio: 3.37 [95 % CI: 1.18-9.65]). This association, however, was not observed in patients with lower baseline LAVI (≤55 ml/m2) but was only seen in those with a baseline LAVI over 55 ml/m2.

CONCLUSION

Our study demonstrated an increase in LAVI after LAAC was related to smaller LAVI or elevated TRPG at baseline. The LAVI increase was significantly associated with subsequent HFH.

Practical guidance and clinical applications of transoesophageal echocardiography. A position paper of the working group of echocardiography of the Hellenic Society of Cardiology

Transoesophageal echocardiography (TOE) is a well-established imaging modality, providing more accurate and of higher quality information than transthoracic echocardiography (TTE) for a wide spectrum cardiac and extra-cardiac diseases. The present paper represents an effort by the Echocardiography Working Group (WG) of the Hellenic Cardiology Society to state the essential steps of the typical TOE exam performed in echo lab. This is an educational text, describing the minimal requirements and the preparation of a meticulous TOE examination. Most importantly, it gives practical instructions to obtain and optimize TOE views and analyses the implementation of a combined two-and multi-dimensional protocol for the imaging of the most common cardiac structures during a TOE. In the second part of the article a comprehensive review of the contemporary use of TOE in a wide spectrum of valvular and non-valvular cardiac diseases is provided, based on the current guidelines and the experience of the WG members.

Advanced Echocardiographic Guidance for Transcatheter Tricuspid Edge-To-Edge Repair

Echocardiography, in all its forms (transthoracic echocardiography [TTE], transesophageal echocardiography [TEE], and intracardiac echocardiography [ICE]), is pivotal for the evaluation, guidance, and follow-up of transcatheter tricuspid edge-to-edge repair (TV-TEER) therapies. Although two-dimensional (2D) echocardiography remains essential, three-dimensional (3D) echo with multiplanar reconstruction (MPR) has revolutionized the field of structural imaging. In addition, the advent of 3D ICE has added an important modality to the imaging toolbox, particularly helpful when intraprocedural TEE images are challenging. In this review, we provide a detailed, step-by-step approach for advanced echocardiographic guidance of TV-TEER using 3D MPR.

Morphological and functional assessment of the left atrial appendage in daily practice: a comprehensive approach using basic and advanced echocardiography with practical tips

Cardioembolic stroke is the most serious and life-threatening complication of atrial fibrillation (AF), with an associated mortality up to 30% at 12 months. Approximately 47% of thrombi in valvular AF and 91% of thrombi in nonvalvular AF are localized in the left atrial appendage (LAA). Therefore, identification or exclusion of LAA thrombi is critical in many clinical situations. It is essential to assess LAA morphology and function using imaging modalities (particularly echocardiography) before, during, and after interventional procedures such as AF ablation and LAA occlusion. This review article describes the anatomical, physiological, and pathological background of the LAA, followed by an assessment of different echocardiographic modalities. Many practical points are included to improve the diagnostic accuracy and to minimize errors during image acquisition and interpretation. In each clinical scenario where LAA is the crucial target, specific and essential information and parameters are collected.

Outcome Prediction score for mitral transcatheter edge-to-edge repair in patients with concomitant significant tricuspid regurgitation

BACKGROUND

Tricuspid regurgitation (TR) adversely affects prognosis following mitral transcatheter edge-to-edge repair (TEER). We aimed to derive a risk stratification tool for patients undergoing TEER for mitral regurgitation while exhibiting significant TR.

METHODS

This is a single-center, retrospective analysis of 217 consecutive individuals referred to an isolated mitral TEER who had moderate-to-severe or greater TR at baseline. The primary outcome was the 1-year composite of all-cause mortality or heart failure hospitalizations. The cohort was randomly split in a 75%-to-25% ratio, creating train (n = 163) and test (n = 54) datasets. Model development, discrimination, and calibration were based on the train dataset. Internal validation was applied to the test dataset.

RESULTS

Overall, 81 (37.3%) patients experienced the primary outcome. After multivariable analysis, a score for predicting the primary outcome was constructed that utilized a 0-to-3 scale, in which each point represented one of three baseline variables independently associated with this combined endpoint: serum B-natriuretic peptide (BNP) level >1,000 pg/mL, qualitative right ventricular (RV) dysfunction on transthoracic echocardiogram, and cardiac implantable electronic device (CIED). C-statistic of the model was 0.66 (95% CI, 0.57-0.75, p = 0.002) and 0.75 (95% CI, 0.61-0.89, p = 0.004) in the train and test datasets, respectively-representing comparable performance to current, more complex tools. Neither this BNP-RV-CIED (BRC) score nor other models were prognostically meaningful in 32 patients excluded from the main analysis who underwent a combined mitral-tricuspid TEER.

CONCLUSION

The BRC score is a simple clinical prediction tool that may aid in the triage of isolated mitral TEER candidates with significant pre-existing TR.

Intraoperative and Intraprocedural Use of 3-Dimensional Transesophageal Echocardiography: An International European Association of Cardiothoracic Anesthesia and Intensive Care Survey of Cardiac Surgical Centers

OBJECTIVE

To assess the intraoperative use of 3-dimensional transesophageal echocardiography (3D TEE) in cardiac surgical centers, the authors created a survey aimed at evaluating the availability of equipment and the use of 3D TEE for specific surgical and interventional procedures and single-image modalities. The respondents were asked to identify the perceived impact on patient management and current limitations to its routine use.

DESIGN

A multiple choice 25-question online survey submitted to the members of the European Association of Cardiothoracic Anesthesia and Intensive Care (EACTAIC) on December 6, 2021, and closed on January 31, 2022.

SETTING

An online survey.

PARTICIPANTS

Registered EACTAIC members in 2021.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

A total of 239 respondents from 44 different countries took part in the survey (27% of the total 903 EACTAIC members). Most respondents (59%) were TEE-certified by the National Board of Echocardiography, European Association of Cardiovascular Imaging (EACVI/EACTAIC), or had a national certificate. Of the respondents, 68% had no formal 3D TEE training. Eight percent of respondents had no 3D machines, whereas 40% had one for each operating room, and 33% had only one for the entire operating room block. 3D TEE was performed most frequently in more than 67% of cases for mitral valve surgery, and in more than 54% of cases for mitral and tricuspid clips, aortic valve, tricuspid valve, and aortic surgery.

CONCLUSION

Current guidelines suggest integrating 3D TEE into all comprehensive examinations. The authors' survey reported that intraoperative 3D TEE was used in the majority of mitral valve surgery and only one-half of the other valve surgeries and transcatheter procedures. Its use may be explained by the availability of 3D machines, trained personnel, and limited time to perform TEE in the operating room. Educational initiatives for training in 3D TEE may further increase its routine use.

Transesophageal echocardiography related complications

Transesophageal Echocardiography (TEE) is an important imaging method for the evaluation of cardiac structure and function, and it holds significant value in the clinical management of cardiovascular diseases. Unlike transthoracic echocardiography (TTE), which is non-invasive, TEE involves semi-invasive intracavity operations, leading to increasing attention to its safety and potential complications. Especially with the increasing demand for TEE applications in clinical practice and the rapid growth in the number of facilities utilizing it, the standardized application and safe operation of TEE technology have become particularly crucial. This article will review the literature and draw upon personal experience to analyze the complications and safety of TEE examinations from a technical perspective.

Transcatheter Therapy for the Tricuspid Valve: A Focused Review of Edge-to-Edge Repair and Orthotopic Valve Replacement

PURPOSE OF REVIEW

Patients with severe tricuspid regurgitation (TR) are at risk for significant morbidity and mortality. Transcatheter tricuspid valve interventions (TTVI) may offer patients less invasive treatment alternatives to surgery. This review evaluates the most common class of device currently used worldwide to treat TR, tricuspid transcatheter edge-to-edge repair (T-TEER) and orthotopic transcatheter tricuspid valve replacement (TTVR), both of which are now approved in the USA and Europe.

RECENT FINDINGS

The first pivotal randomized clinical trial, TRILUMINATE, demonstrated that T-TEER can safely reduce TR and is associated with improved health status outcomes. However, results of this trial have raised questions about whether this device can provide sufficient TR reduction to impact clinical outcomes. Orthotopic TTVR has recently gained attention with initial data suggesting near-complete TR elimination. The current review examines the technical features and anatomic limitations of the most commonly used devices for T-TEER and orthotopic TTVR, discusses the current clinical data for these devices, and offers a theoretical construct for device selection.