Advances in Procedural Echocardiographic Imaging in Transcatheter Edge-to-Edge Repair for Mitral Regurgitation

How to Optimize a 3D Transesophageal Echocardiographic Dataset Using Advanced Editing Tools: A Step-by-Step Guide

The paper provides a step-by-step guide in editing 3D transesophageal echocardiographic datasets. It reiterates the importance of editing as an added value of optimizing echocardiographic images in order to achieve a correct diagnosis and avoid unnecessarily lengthening an invasive examination such as transesophageal imaging. In particular, the process begins with acquiring a comprehensive 3D dataset, optimizing image cropping, and adjusting gain to enhance visualization. Techniques such as rotation, cropping, dual view, and multiplanar reconstruction (MPR) allow for detailed exploration of cardiac structures, facilitating better understanding of conditions such as mitral regurgitation and stenosis. Advanced visualization tools, like photorealistic and glass effects, improve anatomical realism and help accentuate important features for diagnosis. Furthermore, transillumination techniques enhance visualization, making subtle anatomical details more apparent. To conclude, optimizing 3D datasets is essential for accurate anatomical representation and understanding of cardiac pathology, emphasizing the need for careful acquisition and editing during transesophageal echocardiography.

[Transcatheter edge-to-edge repair using MitraClipTM G4 for severe mitral regurgitation in an advanced elderly patient with Barlow disease]

A 91-year-old male patient was admitted with a history of mitral valve prolapse diagnosed by physical examination ten years prior and recent onset of exertional chest discomfort persisting for over one month. Transthoracic echocardiography showed that the anterior leaflet of mitral valve was thickened and prolapsed with severe regurgitation, and transesophageal echocardiography further confirmed that the anterior and posterior leaflets of mitral valve were prolapsed with massive regurgitation (A1, A2, A3, P1 and P2 were all prolapsed). Thus, the diagnosis of Barlow syndrome was considered. Transcatheter edge-to-edge mitral repair was performed with two MitraClipTM G4 XTWs. After a 10 months follow-up, the patient's cardiac function was significantly improved, and the degree of mitral regurgitation was mild.

Computed tomography anatomic predictors of outcomes in patients undergoing tricuspid transcatheter edge-to-edge repair

AIM

To identify anatomical computed tomography (CT) predictors of procedural and clinical outcomes in patients undergoing tricuspid transcatheter edge-to-edge repair (T-TEER).

METHODS AND RESULTS

Consecutive patients undergoing T-TEER between March 2018 to December 2022 who had cardiac CT prior to the procedure were included. CT scans were automatically analyzed using a dedicated software that employs deep learning techniques to provide precise anatomical measurements and volumetric calculations. Technical success was defined as successful placement of at least one implant in the planned anatomic location without single leaflet device attachment. Procedural success was defined as tricuspid regurgitation reduction to moderate or less. Procedural complexity was assessed by measuring the fluoroscopy time. The clinical endpoint was a composite of death, heart failure hospitalization, or tricuspid re-intervention throughout two years. A total of 33 patients (63.6% male) were included. Procedural success was achieved in 22 patients (66.7%). Shorter end-systolic (ES) height between the inferior vena cava (IVC) and tricuspid annulus (TA) (r ​= ​- 0.398, p ​= ​0.044) and longer ES RV length (r ​= ​0.551, p ​= ​0.006) correlated with higher procedural complexity. ES RV length was independently associated with lower technical(adjusted Odds ratio [OR] 0.812 [95% CI 0.665-0.991], p ​= ​0.040) and procedural success (adjusted OR 0.766, CI [0.591-0.992], p ​= ​0.043). Patients with ES right ventricular (RV) length of >77.4 ​mm had a four-fold increased risk of experiencing the composite clinical endpoint compared to patients with ES RV length ≤77.4 ​mm (HR ​= ​3.964 [95% CI, 1.018-15.434]; p ​= ​0,034]).

CONCLUSION

CT-derived RV length and IVC-to-TA height may be helpful to identify patients at increased risk for procedural complexity and adverse outcomes when undergoing T-TEER. CT provides valuable information for preprocedural decision-making and device selection.

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.

Real-Time Multiplanar Reconstruction Imaging Using 3-Dimensional Transesophageal Echocardiography in Structural Heart Interventions

The complexity of structural heart interventions has led to a demand for sophisticated periprocedural imaging guidance. Although traditional 2-dimensional (2D) transesophageal techniques are used widely, new-generation 3D ultrasound probes enable high temporal and spatial resolution. Multiplanar reconstruction of acquired 3D datasets has gained considerable momentum for precise imaging and to increase the validity of measurements. Previously, this technique was used after the acquisition of suitable 3D datasets. Recent advances in technology have enabled the use of live mode for multiplanar reconstruction across different ultrasound vendor platforms. The use of live multiplanar reconstruction can enhance the precision in real-time imaging, enable simultaneous visualization of structures of interest in multiple planes, reduce the need for probe manipulation, and thereby contribute to the success of the procedures. In this narrative review, the authors describe the rationale and utility for 3D transesophageal live multiplanar reconstruction, and outline its use for the structural heart interventions of mitral and tricuspid valve edge-to-edge repair, left atrial appendage occlusion, and the Lampoon procedure. A 3D transesophageal echocardiogram with live-multiplanar reconstruction has the potential to advance guidance of these complex interventions.