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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3737_Библиотеки_им_академика_М_И_Перельмана
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Multimodality Imaging
https://t.me/med1917
ofTricuspid Valve Disease
attheDawn ofTranscatheter
Intervention
SusheelKodali andVratikaAgarwal
Abstract
There is growing interest in the impact of tricuspid valve disease. Multiple studies have
demonstrated that the presence of tricuspid
regurgitation, either in its isolated form or
when co-existent with other valvular disease,
leads to poor outcomes. Surgical repair or
replacement is an option for a limited population fullling specic anatomic and clinical
criteria. Transcatheter intervention of tricuspid valve disease offers a potentially valuable
alternative to surgical treatment. The success
and outcomes of the intervention are heavily
dependent on understanding the tricuspid
valve anatomy and pathophysiology.
Multimodality imaging is the cornerstone
for pre-procedural, peri-procedural as well as
post-procedural assessment and management.
This section will discuss the pathophysiology
of tricuspid valve disease and the role of different imaging modalities in the diagnosis and
preprocedural evaluation of the RV and
S. Kodali (*)
Structural Heart and Valve Center, New York
Presbyterian/Columbia University Medical Center,
NY, New York, USA
e-mail: sk2427@cumc.columbia.edu
V. Agarwal
Structural and Interventional Imaging, New York
Presbyterian/Columbia University Medical Center,
NY, New York, USA
e-mail: va2374@cumc.columbia.edu
TV.We will also discuss the role of imaging in
guiding the choice of therapeutic intervention
and post procedural surveillance and
management.
Keywords
Tricuspid regurgitation · Transcatheter
tricuspid valve intervention · Right heart
disease · Multimodality imaging for tricuspid
intervention
Abbreviations
CT Computed tomography
HF Heart failure
ICE Intracardiac echocardiography
IVC Inferior vena cava
MRI Magnetic resonance imaging
PA Pulmonary artery
PVR Pulmonary vascular resistance
RA Right atrium
RV Right ventricle
SVC Superior vena cava
TA Tricuspid annulus
TEE Transesophageal echocardiography
TEER Transcatheter edge-to-edge repair
TR Tricuspid regurgitation
TTE Transthoracic echocardiography
TTVR Transcatheter tricuspid valve
replacement
TV Tricuspid valve
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
A. M. Kelsey et al. (eds.), Cardiac Imaging in Structural Heart Disease Interventions,
https://doi.org/10.1007/978-3-031-50740-3_3
119
120
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Test your learning and check your understanding of this book’s contents: use the
“Springer Nature Flashcards” app to access
questions using ▶ https://sn.pub/ambACS.
To use the app, please follow the instructions in the chapter “Transcatheter Aortic
Valve Replacement.”
Learning Objectives
1. Be able to describe the pathophysiology and
natural history of tricuspid valve disease.
2. Be able to describe the most common clinical
presentations.
3. Be able to describe use of multimodality
imaging for baseline assessment as well as to
guide choice of intervention type.
4. Be able to describe the role of pre-, intra-, and
post-procedural imaging for optimal patient
outcomes.
Case Study
Patient is an 84-year-old male with chronic
persistent atrial brillation s/p multiple
unsuccessful cardioversion attempts, CKD
III, HFpEF, who presented to the ED for
HF exacerbation. At baseline he is active
but lately noticed increased dyspnea on
exertion and fatigue. Exam revealed an
elevated JVP with prominent V wave and a
respirophasic systolic murmur at the right
lower sternal border and lower extremity
edema. The patient was additionally found
to be in atrial brillation with rapid ventricular rate. He was admitted for further
workup and optimization of his volume status and atrial brillation.
S. Kodali and V. Agarwal
Background andDenitions
Introduction
Tricuspid valve disease poses an extraordinary
health care burden with age-adjusted prevalence
of 0.55% with the highest incidence noted in
women over the age of 75years [1]. Studies suggest that over 1.6 million individuals in the
United States are affected by moderate or severe
tricuspid regurgitation. TR is associated with a
twofold increased cardiac mortality that persists
even after adjustment for potential confounders
[2]. Historically, TR has been underrecognized
and left untreated due (1) an underestimation of
the impact of TR on outcomes and (2) due to a
lack of evidence in support of treatment options
in these patients—many of whom are multimorbid and at high surgical risk. Recent studies associating TR with poor cardiovascular outcomes
have shed light on the importance of early recognition and potentially treatment of tricuspid
regurgitation [3]. There is growing interest in
understanding the pathophysiology, anatomy and
etiology of TR in order to effectively treat it with
lower risk interventions and reduce the overall
healthcare burden imposed by the disease. Recent
advances in transcatheter therapies for the treatment of tricuspid regurgitation and a lack of traditional surgical mortality benet for isolated TV
surgery [4, 5] has generated tremendous interest
in pursuing early treatment.
Tricuspid Regurgitation
TR is the predominant pathology associated with
tricuspid valve. The severity of TR has traditionally been classied via a 3 level grading system
encompassing mild, moderate, and severe, as discussed further below. However, more recently,
Multimodality Imaging ofTricuspid Valve Disease attheDawn ofTranscatheter Intervention
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echocardiographic core-lab analyses from clinical trials of percutaneous therapies for TR have
suggested a 5 category scheme of mild, moderate, severe, massive, and torrential.
Primary TR is often seen in younger population and is usually in the setting of congenital
malformation, endocarditis or trauma.
Secondary TR is encountered far more commonly and is frequently noted in the setting of
left-sided valvulopathy and left ventricular systolic or diastolic dysfunction. Left sided disease
causes increase in pulmonary pressures which in
turn lead to RV remodeling by RV hypertrophy
and eventually RV dilatation. The identication
of the mechanism of tricuspid regurgitation and
the etiology plays a crucial role in determining
the appropriate intervention and choosing an
optimal device for trans-catheter or surgical
intervention.
Classication of TR based on etiology is given
below in Table1.
Tricuspid Stenosis
TS is not commonly seen in native tricuspid
valves. Tricuspid stenosis is often diagnosed in
the presence of small surgical annuloplasty rings
or TV prosthesis. Native TS is often associated
with TR and is seen in disease processes such as
carcinoid disease (causing thickening and xation of the TV leaets) or rheumatic heart disease
(thickening and commissural fusion).
Diagnosis andPre-procedural
Assessment
Given the patient’s signs and symptoms of right
sided heart failure, his murmur, and atrial brillation, he underwent transthoracic echocardiography as part of his initial diagnostic testing. TTE
revealed preserved LV function with mild to
moderate RV dysfunction function, torrential TR
and moderate MR.The patient’s signs and symptoms of volume overload, dyspnea on exertion,
fatigue (likely due to poor cardiac output), and
atrial brillation are all commonly encountered
in severe TR, as listed below.
Clinical Assessment
The clinical presentation mostly depends on etiology of tricuspid regurgitation
– Signs and symptoms of volume overload
– Dyspnea on exertion
– Fatigue due to poor cardiac output
– Congestive hepatopathy
– Arrhythmia (atrial brillation is commonly
encountered)
– Cardiac cachexia
Similarly, the patient’s JVD with V wave prominence, murmur, and lower extremity edema are
among the many signs consistent with severe TR,
as listed below.
Table 1 Classication of TR based on etiology
Primary tricuspid regurgitation Secondary tricuspid regurgitation Prosthetic valve dysfunction
– Myxomatous tricuspid valve
disease
– Tricuspid valve perforation
– Tricuspid valve endocarditis
– Tricuspid valve ail (post
biopsy)
– Carcinoid
– Rheumatic
– Radiation
– Traumatic injury
– Congenital abnormality
(Ebstein’s anomaly)
– Tricuspid regurgitation due to
pacemaker lead impingement
– Atriogenic tricuspid regurgitation
(right atrial dilatation with normal
right ventricle)
– Ventriculogenic tricuspid
regurgitation (RV cardiomyopathy)
– Mixed TR (both atrial and
ventricular dysfunction)
– TR secondary to severe primary
pulmonary hypertension
– TR due to left sided disease with
increased pulmonary pressures and
RV remodeling
– Prosthetic annuloplasty
dysfunction (TS or TR or
both)
– Prosthetic valve
dysfunction (TS or TR or
both)
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S. Kodali and V. Agarwal
Physical Examination
Physical ndings commonly encountered in tricuspid regurgitation are:
– JVD and systolic thrill
– Prominent C and V waves
– RV lift
– S3 gallop due to RV distension
– S4 due to right ventricular hypertrophy
– Holosystolic murmur right sternal border
– Diastolic rumble with TS
– Murmur may be soft or inaudible if there is
torrential or wide-open TR
– Pulsatile hepatomegaly
– Ascites and pedal edema
Cardiac imaging forms the mainstay of diagnostic testing in TR with the goals of:
– Dene tricuspid valve anatomy
– Determine the etiology of tricuspid
regurgitation
– Assess the severity of tricuspid regurgitation
by both qualitative and quantitative methods
– Characterize right ventricular and right atrial
anatomy and function
– Assess for other associated valvular pathology
and left sided function
– Image extracardiac structures—IVC and SVC
– Evaluate feasibility of tricuspid valve
intervention
Transthoracic Echocardiogram (TTE)
TTE is an excellent tool in diagnosing right sided
pathology. TTE helps in identifying the etiology
and mechanism of tricuspid regurgitation and
helps in accurate assessment of degree of tricuspid regurgitation. Tricuspid valve is a complex
structure with multiple and sometimes ill-dened
leaets with variable number of chords and papillary muscles [6]. The proximity of the right heart
to the chest wall aides in good visualization of
the tricuspid valve leaets as well as the right
ventricle. Ideally, both 2D and 3D views should
be attained to characterize the tricuspid valve
anatomy. Quantication of severity of regurgitation is done using 2D color doppler and 3D color
doppler with multi-beat acquisition. The approach
to comprehensive assessment of the tricuspid
valve and right ventricle are addressed in the
American Society of Echocardiography guidelines [7, 8]. The severity of tricuspid regurgitation has traditionally been determined on a 3
grade scale while more recent investigations in
the era of transcatheter tricuspid interventions
have proposed a 5 grade scale (Table2). Each of
these grading systems is based on integration of a
number of quantitative, semi-quantitative, and
qualitative factors with the 5 grade scale subdividing the traditional category of “severe” into
“severe”, “massive,” and “torrential” based on
quantitative metrics [9].
The key views used for comprehensive assess-
ment of tricuspid valve pathology are (Fig.1):
– Parasternal RV inow view with zoomed in
view of the tricuspid valve
– Dedicated tricuspid valve view in parasternal
short axis at the level of the aortic valve
– Apical RV focused view to assess right ven-
tricular size and function
– Dedicated RV view in apical 4-chamber view
for strain assessment and 3D of the RV for
assessment of ejection fraction.
– Zoomed in view of the tricuspid valve in
4-chamber view with and without color
assessment
– 3D acquisition both with and without color
should be done in multiple views (Fig.2). 2D
image should be optimized prior to switching
to 3D to allow for better resolution and frame
rate.
– Subcostal view for IVC dimension and com-
pressibility and for hepatic vein reversal.
In cases where there are discrepancies between
physical exam ndings and TTE ndings, or
clinical history and TTE ndings, or TTE ndings are conicting/unclear, or invasive therapies
are being considered, further evaluation with
either TEE or cardiac MRI should be
considered.
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5 Class Grading Scheme for TR
Table 2
Variable Mild Moderate Severe Massive Torrential
2
2
Severe valve
lesions (ail,
severe retraction,
large perforation)
Large central jet
or eccentric wall
impinging jet of
variable size
Large throughout
systole
Dense, often
triangular
60–79mm
95–114mm
2
2
Qualitative
measures
TV
morphology
RV and RA
size
Inferior vena
cava diameter
Color ow jet
area
Flow
convergence
zone
Continuous
wave Doppler
jet
VC (biplane) <3mm 3–6.9mm 7–13mm 14–20mm
EROA (PISA) <20mm
3D VCA or
quantitative
EROA
Normal or
mildly
abnormal
leaets
Usually
normal
Normal
<2cm
Small,
narrow,
central
Not visible,
transient or
small
Faint/
partial/
parabolic
NA NA 75–94mm
Moderately
abnormal
leaets
Normal or
mild dilation
Normal or
mildly dilated
2.1–2.5cm
Moderate
central
Intermediate in
size and
duration
Dense,
parabolic, or
triangular
2
20–39mm
Severe valve
lesions (ail,
severe retraction,
large perforation)
Usually dilated Usually dilated Usually dilated
Dilated >2.5cm Dilated >2.5cm Dilated >2.5cm
Large central jet
or eccentric wall
impinging jet of
variable size
Large throughout
systole
Dense, often
triangular
2
40–59mm
123
Severe valve
lesions (ail,
severe retraction,
large perforation)
Large central jet
or eccentric wall
impinging jet of
variable size
Large throughout
systole
Dense, often
triangular
≥21mm
≥80mm
≥115mm
2
2
Cardiac Magnetic Resonance (CMR)
CMR provides an adjunctive imaging modality
to TTE for the diagnosis and quantication of
TR.Similar to echo, it can provide both qualitative and quantitative assessment of regurgitant
lesions [10]. Quantitative assessment of TR by
CMR can be performed with one of several
methods. First, the effective regurgitant orice
area can be directly measured using short axis
images through the annular plane. However, this
can be challenging in scenarios where the annular plane is difcult to dene such as in Ebstein’s
anomaly or with severe leaet tethering. An
alternative method to estimate TR is to subtract
RV stroke calculated from RV cine images from
forward stroke volume in the pulmonary artery
calculated with the phase contrast sequence
(Fig. 3). This will provide regurgitant volume
and regurgitant fraction. In addition to quantitating regurgitant volumes, CMR can also be used
to estimate pulmonary pressures with its ability
to estimate a peak systolic velocity across the tricuspid valve which can then be used to estimate
PA pressures. However this calculation may be
more accurate with CMR than echo due to its
ability to get a perfectly on-axis measurement
which can be challenging with TTE in some
patients.
Due to its high spatial and temporal resolution, tricuspid valve leaet anatomy as well as
pathology can also be assessed by CMR.Leaet
length, morphology, tenting, prolapse and thickening can all be assessed using sequential thin
slice imaging. Presence of arrhythmia often leads
to motion artifact. Real time cine imaging without breath hold instructions are used in the
patients with arrhythmia however the image resolution in such cases is suboptimal. Shortened free
breathing real time acquisition may be used to
offset this problem.
CMR also provides accurate and reproducible
assessment of RV function, wall motion abnormality, RV volume and tissue characterization.
Imaging protocols should account for the dilation
of the right ventricle and right atrium and include
4-chamber, RV inow- outow and RV short axis
images in its entirety. Short- axis cine images are
typically used for volumetric measurements by
tracing endocardial borders. Right ventricular
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S. Kodali and V. Agarwal
Fig. 1 The key views for comprehensive assessment of tricuspid valve pathology
ejection fraction and stroke volume are derived
by using the RV end diastolic and systolic volumes. CMR is considered gold standard in the
assessment of RV volumes and function [11, 12].
It has been shown in multiple studies that 2D and
3D echocardiography often underestimates
chamber volumes [13, 14]. CMR also plays a
unique role in identifying right ventricular pathology without use of ionizing radiation. Right ventricular tissue characterization is possible using
native T1 imaging and delayed gadolinium
enhancement. Delayed gadolinium enhancement
provides assessment of dysfunction in myocarditis, myocardial infarction, inltrative disease,
trauma as well as pulmonary hypertension.
As noted above, CMR is a great tool for qualitative and quantitative assessment of tricuspid
regurgitation. However, its clinical application is
limited by the complexities of acquiring the scans
in elderly patients with multiple comorbidities.
The requirement for long scan times with breath
holds makes it challenging for some patients.
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Fig. 2 3-dimensional assessment of tricuspid regurgitation with and without color
125
Fig. 3 Assessment of right ventricular volumes in diastole and systole using RV cine imaging to eatimate right ventricular stroke volume
TEE andComputed Tomography:
Diagnostic Imaging andProcedural
Planning
tous interatrial septum or atrial septal devices
due to acoustic shadowing of the tricuspid valve
leaets as the ultrasound beam crosses these
structures. Acoustic shadowing is often encoun-
Transesophageal Echocardiogram
(TEE)
Similar to cardiac MRI, TEE can play an important role in the diagnostic evaluation of TR when
there are discrepancies between clinical and
TTE ndings or uncertainty regarding TTE ndings. In addition, TEE also allows for careful
assessment and quantication of left sided
pathology which may be contributing to this disease process [15]. Finally, TEE is crucial in pro-
tered in mid- esophageal imaging. Imaging from
the distal esophagus and the stomach allows for
cleaner views of the TV due to improved proximity between the TV and the imaging probe
(Fig.4). Three-dimensional imaging allows for
careful delineation of the TV leaets, aides in
understanding the pathology and allows for planning the interventional procedures.
The key views for comprehensive TEE imaging of the tricuspid valve are:
cedural planning. TEE examination of TV should
be done at various levels and multiplane angles
to allow for complete visualization and assessment of the tricuspid valve apparatus and the
right ventricle. Visualization of the TV can be
sometimes challenging by TEE in patients with a
horizontal heart, left sided prosthesis, lipoma-
– Mid-esophageal 4-chamber at 0° rotation and
orthogonal biplane view
– Mid-esophageal TV commissural view at
60°–90°
– Deep esophageal 0°/90° orthogonal plane
imaging
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Fig. 4 TEE assessment of the degree of tricupid regurgitation and assessment of annular dimensions using 3- dimensional
MPR
S. Kodali and V. Agarwal
– Deep esophageal RV inow outow view at
60°–90°
– Trans gastric short axis view of the TV at
20°–60°
– Deep gastric view at 0° and at higher angles of
120°–160° allows for alignment of the doppler beam to the jet.
– 3D assessment should be performed at multi-
ple levels. Deep gastric and transgastric views
may often provide cleaner views of the tricuspid valve and hence may be optimal for 3D
assessment.
Cardiac Computed Tomography (CT)
Use of cardiac gated CT has become an integral
part of evaluating patients with structural heart
disease especially prior to transcatheter intervention. Pre-procedural planning with cardiac CTA
prior to transcatheter aortic valve replacement
has become routine. However, the role in evaluation of the right-sided heart disease is less established but with the emergence of transcatheter
therapies for tricuspid regurgitation there is
increasing interest. There are several advantages
to cardiac CT over echocardiography including
reproducibility, ability to image patients with
complex cardiac disease including those with
pacemakers and relatively short scan times (espe-
cially in relation to cardiac MRI). However, the
ability to accurately interpret a cardiac CT
depends on the quality of the images obtained.
Obtaining a CT scan that allows for accurate
interpretation of right sided anatomy requires
homogeneous opacication of both the right ventricle and right atrium. In patients with severe tricuspid regurgitation, there are several challenges.
To start, the majority of patients are in atrial brillation which can result in motion or misregistration artifact. This results in blurring of cardiac
structures making accurate interpretations difcult. Care should be taken to optimize scans in
these patients by considering the following. First,
if tolerated, the use of low dose beta blockers
should be considered if patient is tachycardic.
Second, capabilities of the scanners should be considered and images should be obtained on the best
available machine. The use of a CT with a large
detector array (320 slice) will provide the ability to
capture the entire region of interest in one acquisition. This will minimize the risk of misregistration
artifact. In addition, it will shorten the breath hold
required, which can be challenging in elderly
patients with heart failure. The use of newer dual
source scanners with higher temporal resolution
can also minimize this artifact. Finally, although it
results in higher radiation, the use of retrospective
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ECG gating and low-pitch helical scanning will
minimize the risk of artifact in patients with atrial
brillation. Another challenge often encountered
in patients with TR is the presence of concomitant
renal dysfunction. The ability to accurately interpret cardiac structures requires the use of contrast
which can worsen renal function. In addition,
homogenuous opacication of the right side can
be challenging. Standard cardiac CT protocols
designed for left sided cardiac structures result in
heterogenous attenuation of right sided structures
resulting in uninterpretable scans. It is critical to
develop individualized protocols for patients with
TR that focus on obtaining adequate opacication
while minimizing contrast [16, 17].
Obtaining a multiphasic CT encompassing the
entire cardiac cycle is critical for allowing the
selection of the best phases (i.e. those with the
least artifact) for analysis of the various structures
of interest. In addition, it allows for assessment of
changes in RA and RV volumes between systole
and diastole. Evaluation of right ventricular function is feasible through a semi-automated segmentation of the RV through 10 phases of the cardiac
cycle [16]. Studies have demonstrated good correlation to MRI in assessment of RV function [18].
Evaluation of the CT in patients with TR should
be performed in the context of the intervention
being planned. The structures of interest will be
different depending on whether the intervention
planned is transcatheter edge to edge repair, transcatheter annuloplasty or percutaneous valve
replacement. Regardless, a careful analysis evaluating all of the key structures should be performed.
Tricuspid leaet morphology including number of
leaets and location of commissures can be seen
(Fig.5). This can be useful when planning edge to
edge repair. Dynamic reconstructions throughout
the cardiac cycle can demonstrate leaet tethering
and gaps at intended location for the edge to edge
repair. This information can supplement the TEE
data to provide an assessment of the likelihood of
a good quality repair.
In patients intended for transcatheter replacement, analysis of the right sided structures along
with the tricuspid valve apparatus is required.
Multiplanar reconstructions of the tricuspid
annulus are performed allowing measurements of
annular dimensions which are necessary for siz-
ing the prosthesis. Multiple measurements should
be taken including max and min dimensions, area
and perimeter (Fig. 5). Sizing algorithms will
vary depending on the prosthesis being chosen.
There can be signicant changes in size between
systole and diastole. Ideally measurements
should be taken in diastole which is typically
when the largest dimensions are seen. However,
care should be taken to review all phases and use
the ones with the least artifact. Beyond assessment of the annulus, the entire TV apparatus
should be reviewed. Care should be taken to note
the location and number of papillary muscles
which can interact with the prosthesis or the
delivery system. In addition, RA and RV dimensions should be noted to ensure there is room for
the delivery catheter to safely deliver the prosthesis. In addition to these measurements, location
of pacemaker leads in the RV as well as the trajectory across the tricuspid annulus can be seen
nicely in multiplanar reconstructions. Finally, the
location and approach of the inferior vena cava
into the RA should be evaluated. There is signicant variability of this among patients and it can
signicantly impact the ability of the delivery
catheter to reach the tricuspid annulus in a coaxial manner which is critical for most devices [19].
Although transcatheter edge to edge repair and
percutaneous tricuspid valve replacement are the
primary therapies being evaluated, there are several
other approaches being investigated such as transcatheter annuloplasty and heterotopic valve replacement. In patients being considered for annuloplasty,
one other important consideration is the location of
the right coronary artery which often tracks near the
anterior leaet. Due to this location, it could be
injured during annuloplasty. Reconstructions showing the location of the RCA in relation to the TV
annulus is useful for preprocedural planning. If
annuloplasty is being considered, it is important that
the acquisition protocol for the CT ensures adequate
contrast opacication on the left side to ensure adequate visualization of the coronary artery. This is
the only scenario in which opacication of left sided
structures is necessary when evaluating for tricuspid
intervention. In patients being considered for heterotopic placement of bioprosthetic valves in the
superior and inferior vena cava, careful measurements of these dimensions for appropriate sizing
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ab
cd e
S. Kodali and V. Agarwal
Fig. 5 CT images showing annular assessment (Panel a),
RV and RA height (Panel b), IVC offset to Tricuspid
Annulus (Panel c), IVC angulation (Panel d and e). In
should be performed in multiplanar reconstructions
that are coaxial to the structure.
Cardiac Catheterization
andFluoroscopic Evaluation
The evaluation of patients with severe tricuspid
regurgitation has typically involved a right and left
heart catheterization. Although coronary angiography is standard in patients planned for surgical
repair or replacement, the role in patients undergoing transcatheter intervention remains unclear. It is
unlikely that coronary revascularization would
impact the severity of tricuspid regurgitation. It
should be considered primarily in patients where it
is clinically indicated for other reasons.
The role of right heart catheterization in
patients with TR is critical. First, it may necessary
to ensure that patients are medically optimized
prior to intervention. It is important to note that
TR is dynamic. Optimization of volume status
can signicantly improve regurgitation and mitigate the need for intervention. Secondly, right
Panel e, red arrow illustrates trajectory of IVC towards
septum and away from tricuspid annulus (red circle)
heart catheterization to evaluate the presence of
pulmonary hypertension is an important consideration. Recent studies have demonstrated that
pulmonary hypertension (PAPs >50mmHg) is a
poor prognostic sign in patients with TR even
after successful intervention [20]. This same
study also demonstrated that non-invasive assessment of pulmonary pressures by echocardiography is poor with a sensitivity of only 55%.
Therefore routine right heart catheterization in
patients with TR is recommended not only for
optimization but also for prognosis.
Fluoroscopy remains an important adjunct to
echocardiography during transcatheter intervention. Based on the preoperative CT, uoroscopic
angles that are coaxial to the tricuspid annulus
can be calculated. During the procedure, uoroscopy in these angles can be useful to ensure
the device is approaching the tricuspid valve in
a coaxial manner, which can be critical for success. In addition, identication of the right coronary artery either by placement or angiography
can serve as an important landmark especially
in transcatheter annuloplasty procedures.
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