Recommendations for Special Competency in Echocardiographic Guidance of Structural Heart Disease Interventions: From the American Society of Echocardiography

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.

Current Status of Tricuspid Valve Interventions in Asia Pacific Region

Transcatheter tricuspid interventions are becoming increasingly more common in Asia Pacific. In the past decade, clinicians in Asia Pacific have worked with a multitude of new transcatheter tricuspid technologies. A standardized clinical algorithm to diagnose symptomatic tricuspid regurgitation to increase patient access to novel right heart therapies has not yet been identified. Anatomic diversity in the Asia Pacific patient population; disease prevalence patterns; and socioeconomic, cultural, and local health structures represent unique challenges in the treatment of these patients with right heart failure. As advancements are made in right heart failure and transcatheter tricuspid technologies, hopefully more patients can be treated not just in Asia Pacific, but across the entire world.

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.

Left Ventricular Hypertrophy Regression Following Transcatheter Aortic Replacement: A Comparison of Self-Expanding Versus Balloon-Expandable Prostheses

There are limited reports on the impact of prosthesis-patient mismatch (PPM) on the regression of left ventricular hypertrophy (LVH) after transcatheter aortic valve replacement (TAVR). We compared the relative effects of supra-annular, self-expanding (SE) versus intra-annular, balloon-expandable (BE) prostheses on TAVR LVH regression. Regression of left ventricular mass index (LVMi) was evaluated in 168 consecutive TAVR patients, including 60 treated with SE valves (Evolut series) and 108 treated with BE valves (Sapien 3). All patients had LVH determined at baseline by echocardiography and had repeat LVMi measurements at a mean follow-up time of 707 ± 528 days. SE patients were more likely female (68.3% vs 46.3%, p = 0.007), but otherwise, the 2 cohorts did not differ with respect to baseline demographics and Society of Thoracic Surgeons risk score. SE patients had a higher effective orifice area indexed to body surface area after TAVR (0.98 ± 0.29 vs 0.86 ± 0.25 cm²/m², p = 0.006), with lower mean aortic valve gradients (9.9 ± 6.5 vs 12.8 ± 5.8 mm Hg, p = 0.003) and a lower prevalence of moderate/severe PPM (33.3% vs 49.1%, p = 0.049). On follow-up, changes in LVMi were similar between the SE and BE groups, with similar absolute changes in LVMi (19.2 ± 26.8 vs 21.9 ± 31.7 g/m2, p = 0.578) and relative LVMi decrease (14.0 ± 19.5 vs 16.2% ± 24.2%, p = 0.547). No difference in LVMi regression was also noted comparing combined SE/BE patients with moderate/severe PPM versus those without PPM. In conclusion, despite differences in effective orifice area indexed to body surface area, mean aortic valve gradient, and PPM after TAVR, the degree of LVH regression during intermediate follow-up did not differ between patients receiving supra-annular SE and intra-annular BE prostheses.

Clinical Impact of Baseline Frailty Status and Residual Mitral Regurgitation After Transcatheter Edge-to-Edge Repair: Insights From the OCEAN-Mitral Registry

BACKGROUND

The Clinical Frailty Scale (CFS) is a useful frailty marker for predicting clinical outcomes in patients undergoing invasive therapy. However, the clinical impact of CFS after transcatheter edge-to-edge repair in patients with mitral regurgitation (MR) remains unclear. This study aimed to elucidate the association between the baseline frail status defined by the CFS and clinical outcomes with or without postprocedural MR ≥2+ (post-MR ≥2+) after transcatheter edge-to-edge repair.

METHODS AND RESULTS

Based on a Japanese multicenter registry (OCEAN [Optimized Catheter Valvular Intervention]-Mitral), data from 2078 patients with MR who underwent transcatheter edge-to-edge repair were analyzed. The patients were classified into 5 groups: CFS 1 to 3, 4, 5, 6, and ≥7. The procedural and clinical outcomes and post-MR ≥2+ were compared among the groups. All-cause mortality for up to 2 years was explored using Cox proportional hazards regression analysis. Although the rates of acute procedural success and post-MR ≥2+ were similar, all-cause mortality at 2 years was significantly increased across the 5 CFS categories (15.5%, 23.8%, 27.7%, 34.6%, and 48.8%, respectively, P<0.001). The incremental CFS categories and post-MR ≥2+ were independent predictive risk factors of all-cause mortality (all P<0.05). Among the patients with 5 CFS categories, the incidence of all-cause mortality was higher in those with post-MR ≥2+ than in those without (all P<0.05).

CONCLUSIONS

Although prognosis was poor in patients with higher CFS grade after transcatheter edge-to-edge repair, minimizing modifiable factors of residual MR is warranted to improve the clinical outcomes.

REGISTRATION INFORMATION

URL: https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000027188; Unique identifier: UMIN000023653.

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.

Addressing the Occupational Risk of Radiation Exposure in the Evolving Field of Interventional Echocardiography

Interventional echocardiography (IE) is a relatively new subspecialty in the field of cardiology that has rapidly evolved to occupy a critical role in the treatment of structural heart disease. Despite this, clear competency guidelines are only now being issued, and, of pressing importance, the health risks associated with the profession, particularly occupational radiation exposure, still need to be recognized and appropriately addressed for both specialists and trainees in IE as well as for supporting sonographers. This review will briefly discuss the extensive training interventional echocardiographers need in advanced imaging modalities and will then present standard measures as well as possible innovative devices that can be implemented to reduce ionizing radiation exposure for those working in the field of IE.

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.

Radiation Exposure to the Interventional Echocardiographers and Sonographers: A Call to Action

Interventional echocardiography is a rapidly growing field within the disciplines of cardiology and anesthesiology, with the rise of advanced transcatheter procedures making skilled imagers more important than ever. However, these procedures also involve frequent manipulation of the transesophageal echocardiography probe, which means interventional echocardiographers (IEs) are at risk of long-term occupational radiation exposure. Studies have shown that radiation exposure is linked to various health issues, including cancer, cataracts, hypertension, hyperlipidemia, endothelial dysfunction, vascular aging, and early atherosclerosis. While there is increasing awareness of the occupational radiation dose limits and the need for better shielding methods, the importance of radiation safety for the IE is still not sufficiently prioritized in most cardiac catheterization laboratories/hybrid operating rooms. This is partly due to a paucity of studies looking at long-term radiation exposure to the IE, as this field is newer than that of interventional cardiologists.

Transcatheter Mitral Valve Intervention: Current and Future Role of Multimodality Imaging for Device Selection and Periprocedural Guidance

Mitral regurgitation (MR) is a broadly diffuse valvular heart disease (VHD) with a significant impact on the healthcare system and patient prognosis. Transcatheter mitral valve interventions (TMVI) are now well-established techniques included in the therapeutic armamentarium for managing patients with mitral regurgitation, either primary or functional MR. Even if the guidelines give indications regarding the correct management of this VHD, the wide heterogeneity of patients' clinical backgrounds and valvular and heart anatomies make each patient a unique case, in which the appropriate device's selection requires a multimodal imaging evaluation and a multidisciplinary discussion. Proper pre-procedural evaluation plays a pivotal role in judging the feasibility of TMVI, while a cooperative work between imagers and interventionalist is also crucial for procedural success. This manuscript aims to provide an exhaustive overview of the main parameters that need to be evaluated for appropriate device selection, pre-procedural planning, intra-procedural guidance and post-operative assessment in the setting of TMVI. In addition, it tries to give some insights about future perspectives for structural cardiovascular imaging.

COMPArison of Multi-Point Pacing and ConvenTional Cardiac Resynchronization Therapy Through Noninvasive Hemodynamics Measurement: Short- and Long-Term Results of the COMPACT-MPP Study

Invasive hemodynamic studies have shown improved left ventricular (LV) performances when cardiac resynchronization therapy/defibrillator is delivered through multipoint pacing (MPP). Nowadays, strategies have become available that allow studying the same hemodynamic parameters at a noninvasive level. The aim of the present study was to evaluate the clinical implication of using a patient-tailored approach for cardiac resynchronization therapy programming based on noninvasively assessed LV hemodynamics to identify the best biventricular pacing modality between standard single-site pacing (STD) and MPP for each patient. Therefore, 51 patients with heart failure (age 69 ± 9 years, 35 men, 27% ischemic etiology) implanted with cardiac resynchronization therapy/defibrillator underwent noninvasive LV function assessment through photoplethysmography before hospital discharge for addressing dP/dt and stroke volume in both pacing modalities (STD and MPP). The modality that performed better in terms of hemodynamic improvement was permanently programmed. Global longitudinal strain (GLS) was also assessed, and repeated at 3 months. Compared with intrinsic rhythm (928 ± 486 mm Hg/s), dP/dtmax showed a trend to increase in both biventricular pacing modes (1,000 ± 577 mm Hg/s in STD, 1,036 ± 530 mm Hg/s in MPP, p = NS). MPP was associated with a wider hemodynamic improvement than was STD and was the modality of choice in 34 of 51 patients (67%). GLS at predischarge did not differ between groups (-10.3 ± 3.8% vs -10.2 ± 3.5%), but significant improvement of ejection fraction at 1 month (34.4 ± 5.3%, p <0.001) and of GLS at 3 months (-12.9 ± 2.9%, p <0.005) was observed across the entire cohort. At 3 months, 77% of patients were classified as responders. Interestingly, long-term (3 years) follow-up unveiled a reduction in all-cause mortality in the MPP group compared with the STD group. In conclusion, cardiac resynchronization therapy programming guided by acute noninvasive hemodynamics favored MPP modality and caused short-term LV positive remodeling and improved long-term outcomes. Clinical Trial Registration: URL: http://www.clinicaltrials.gov. Unique identifier: NCT04299360.

A systematic methodology for epicardial and epiaortic echocardiography in swine research models

Background

Perioperative echocardiography is of paramount importance during cardiac surgery. Nonetheless, in the experimental large-animal setting, it might be challenging obtaining optimal imaging when using conventional imaging acquisition techniques, such as transthoracic and transesophageal screenings. Open-chest surgery allows epicardial echocardiographic assessment with direct contact between probe and heart, thus providing superior quality. Standard protocols regarding the use of epicardial ultrasound in swine for research purposes are lacking.

Methods

Epicardial echocardiography was performed in 10 female German Landrace pigs undergoing cardiac surgery. A structured and comprehensive protocol for epicardial echocardiography was elaborated including apical, ventricular long and short axis, as well as epiaortic planes. All experiments were approved by the local board for animal welfare and conducted in accordance with the German animal protection law (TierSchG) and the ARRIVE guidelines.

Conclusions

Systematic protocols using epicardial echocardiography may serve as an additional tool to assess cardiac dimensions and function in experimental scenarios with swine models.

The Interventional Imager: How Do We Train the Next Interventional Imagers?

With the increase in structural heart procedural volume, interventional imagers are required. Multiple imaging modalities exist to guide these procedures. With comprehensive understanding of pathology, anatomy, and procedures, an advanced imager plays an important role in the heart team. Imaging training is part of general cardiology fellowship. Current structures do not provide adequate procedural time to fill the role. Interested graduates pursue advanced training by either focusing on echocardiography and procedural imaging or multidetector computed tomography and cardiac magnetic resonance. This yields individuals with different expertise.

Comprehensive Training Model for Procedural Guidance of Transcatheter Mitral Valve Edge-to-Edge Repair: Divide and Conquer Approach

Transcatheter edge-to-edge repair (TEER) of the mitral valve is a complex procedure requiring continuous image guidance with 2-dimensional and 3-dimensional transesophageal echocardiography. In this context, the role of the echocardiographer is of paramount importance. Training in interventional echocardiography for procedures such as TEER requires comprehending the complicated workflow of the hybrid operating room and advanced imaging skills that go beyond traditional echocardiography training to guide the procedure. Despite TEER being more commonly performed, the training structure for interventional echocardiographers is lagging, with many practitioners not having any formal training in image guidance for this procedure. In this context, novel training strategies must be developed to increase exposure and aid training. In this review, the authors present a step-wise approach to training for image guidance during TEER of the mitral valve. The authors have deconstructed this complex procedure into modular components and have incremental stages of training based on different steps of the procedure. At each step, trainees must demonstrate proficiency before advancing to the next step, thus ensuring a more structured approach to attaining proficiency in this complex procedure.

Echocardiographic Imaging in Transcatheter Structural Intervention: An AAE Review Paper

Transcatheter structural heart intervention (TSHI) has gained popularity over the past decade as a means of cardiac intervention in patients with prohibitive surgical risks. Following the exponential rise in cases and devices developed over the period, there has been increased focus on developing the role of "structural imagers" amongst cardiologists. This review, as part of a growing initiative to develop the field of interventional echocardiography, aims to highlight the role of echocardiography in myriad TSHIs available within Asia. We first discuss the various echocardiography-based imaging modalities, including 3-dimensional echocardiography, fusion imaging, and intracardiac echocardiography. We then highlight a selected list of structural interventions available in the region-a combination of established interventions alongside novel approaches-describing key anatomic and pathologic characteristics related to the relevant structural heart diseases, before delving into various aspects of echocardiography imaging for each TSHI.

Impact of Percutaneous Mitral Valve Repair on Left Atrial Strain and Atrial Fibrillation Progression

Transcatheter edge-to-edge repair (TEER) currently represents a valuable therapeutic option for patients with severe mitral regurgitation (MR) considered at high surgical risk. Besides symptoms and left ventricular (LV) echocardiographic improvements upon TEER, it has been postulated that left atrial (LA) function plays a prognostic role. The aims of our study were to evaluate LA changes after TEER, measured by two-dimensional speckle-tracking echocardiography analysis (2D-STE), their association with atrial fibrillation (AF) occurrence, and relative arrhythmic burden. We considered in a single-center study 109 patients affected by symptomatic severe MR undergoing TEER from February 2015 to April 2022. By 2D-STE, LA reservoir (R_s), conduct (D_s), and contractile (C_s) strains were assessed along with four-chamber emptying fraction (LAEF-4CH) before, 1, 6, and 12 months following TEER. Statistical analysis for comparison among baseline, and follow-ups after TEER was carried out by ANOVA, MANOVA, and linear regression. Successful TEER significantly improved LV dimensions and LA performances, as indicated by all strain components, and LAEF-4CH after 1 year. Strikingly, a significant reduction in arrhythmic burden was observed, since only one case of subclinical AF detected by a previously implanted cardiac electronic device was found in the cohort of sinus rhythm patients (n = 48) undergone TEER; in addition, ventricular rate was reduced in the AF cohort (n = 61) compared to baseline, together with few episodes of nonsustained ventricular tachycardias (5/61, 8.2%) after MR improvement. Overall, TEER was associated with improved cardiac performance, LA function amelioration, and reduced arrhythmic burden.