Multimodality Imaging Approach for Planning and Guiding Direct Transcatheter Tricuspid Valve Annuloplasty

Massimiliano Mariani, MD, Michela Bonanni, MD, Andreina D’Agostino, MD, Giuseppe Iuliano, MD, Alessia Gimelli, MD, Michele Alessandro Coceani, MD, Simona Celi, PhD, Giuseppe Massimo Sangiorgi, MD, and Sergio Berti, MD

Interest in transcatheter treatment of tricuspid regurgitation (TR) has grown significantly in recent years due to increasing evidence correlating TR severity with mortality and to limited availability of surgical options often considered high-risk in these patients. Although edge-to-edge repair is currently the main transcatheter ther-apeutic strategy, tricuspid valve direct annuloplasty can also be performed safely and effectively to reduce TR and improve heart failure symptoms and quality of life. In the annuloplasty procedure, an adjustable band is implanted around the tricuspid annulus to reduce valvular size and improve TR. Patient selection and careful preoperative imaging, including transthoracic echocardiography, transesophageal echocardiography, and computed tomography, are critical for procedural success and proper device implantation. Compared to edge-to-edge repair, perioperative imaging with transesophageal echocardiography and fluoroscopy is particularly challenging. Alignment and insertion of the anchors are demanding but essential to achieve good results and avoid damaging the surrounding structures. The presence of shadowing artifacts due to car-diac devices makes the acquisition of good-quality images even more challenging. In this review, we discuss the current role of multimodality imaging in planning direct transcatheter tricuspid valve annuloplasty and describe all procedural steps focusing on echocardiographic monitoring.

Accreditation Statement: 

The American Society of Echocardiography is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The American Society of Echocardiography designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program, the American Board of Pediatrics (ABP) MOC program, and/or the American Board of Anesthesiology’s (ABA) Maintenance of Certification in Anesthesiology Program® or MOCA 2.0®. It is ASE’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM and ABP MOC points and/or ABA MOCA 2.0®.   Physicians will earn MOC and/or MOCA 2.0 points equivalent to the amount of CME credits claimed for the activity.

ARDMS and CCI recognize ASE’s certificates and have agreed to honor the CME credit hours toward their registry requirements for sonographers.

• Release Date: April 1, 2024
• Expiration Date April 1, 2025 - CME/MOC must be claimed by this date.

Learning Objectives:

1. Define the shift from conservative management of TR to appropriate intervention and prevention 
2. Classify the devices available for tricuspid intervention 
3. Intentionally develop an intra-procedural imaging protocol 
4. Consolidate imaging from multiple sources to facilitate patient selection 
5. Anticipate imaging in challenging RV and valvular anatomy

Accreditation Statement: 

The American Society of Echocardiography is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education for physicians.

The American Society of Echocardiography designates this activity for a maximum of 1.5 AMA PRA Category 1 Credit(s)™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program, the American Board of Pediatrics (ABP) MOC program, and/or the American Board of Anesthesiology’s (ABA) Maintenance of Certification in Anesthesiology Program® or MOCA 2.0®. It is ASE’s responsibility to submit participant completion information to ACCME for the purpose of granting ABIM and ABP MOC points and/or ABA MOCA 2.0®.   Physicians will earn MOC and/or MOCA 2.0 points equivalent to the amount of CME credits claimed for the activity.

ARDMS and CCI recognize ASE’s certificates and have agreed to honor the CME credit hours toward their registry requirements for sonographers.

• Release Date: April 1, 2024
• Expiration Date April 1, 2025 - CME/MOC must be claimed by this date.

Disclosures:

ASE is committed to ensuring that its educational mission, and all accredited continuing educational programs provide a protected space to learn, teach, and engage in scientific discourse free from influence from organizations that may have an incentive to insert commercial bias into education.

While a monetary or professional affiliation with an ineligible company does not necessarily influence a speaker’s presentation, the Standards for Integrity and Independence in Accredited Continuing Education and policies of the ACCME require that all financial relationships with ineligible companies* be identified and mitigated prior to engaging in an accredited CE activity. In accordance with these policies, ASE actively identified relevant financial relationships between faculty in control of this accredited CE activity and ineligible companies and implemented mitigation strategies to eliminate any potential influence from persons or organizations that may have an incentive to insert commercial bias in this activity. (*Companies that are ineligible to be accredited in the ACCME System (“ineligible companies”) are those whose primary business is producing, marketing, selling, reselling, or distributing healthcare products used by or on patients.)

At the time this article was published, the authors reported no actual or potential conflict of interest relative to the content.

Members of the ASE CME Committee members (not serving as faculty) do not have any financial relationships with ineligible companies.  Click here for a list of these members.

None of the ASE staff who were involved in the planning and implementation of this educational activity have relevant financial relationship(s) to disclose with ineligible companies.  Click here for a list of ASE staff members.

No commercial support was provided for this activity.

• Contact:
  ASE Learning Hub