Faculty Bibliography

BACKGROUND:The TRISCEND II (EVOQUE Transcatheter Tricuspid Valve Replacement: Pivotal Clinical Investigation of Safety and Clinical Efficacy Using a Novel Device) trial demonstrated clinical benefits for transcatheter tricuspid valve replacement (TTVR) with the EVOQUE system over medical therapy for the primary safety and effectiveness endpoint to 1 year. OBJECTIVES/OBJECTIVE:The authors report echocardiographic outcomes at 1 year for the randomized cohort and evaluate hemodynamic and structural changes. METHODS:The multicenter, prospective TRISCEND II trial enrolled 400 patients with severe, symptomatic tricuspid regurgitation (TR) and randomized them in a 2:1 ratio to TTVR (n = 267) or medical therapy (control) (n = 133). The secondary echocardiographic endpoint was reduction in TR severity from baseline to discharge. Echocardiograms were evaluated by an independent echocardiographic core laboratory. RESULTS:All patients had severe TR at baseline; at discharge, 95.5% of patients who underwent TTVR had mild TR. On paired analysis from baseline to 1 year, 95.3% of patients who underwent TTVR and 2.3% of control patients achieved mild TR. Between baseline and 1 year, the mean inferior vena cava diameter decreased significantly more for patients who underwent TTVR (normal breathing P < 0.001, forced inhalation P = 0.038). Patients who underwent TTVR experienced greater improvements in diastolic right ventricular (RV) size (P < 0.05) and larger decreases in RV systolic function (P < 0.001), consistent with reduced preload from TR reduction. RV stroke volume and cardiac output increased significantly in patients who underwent TTVR (P < 0.001) but not in control patients. CONCLUSIONS:One-year echocardiographic outcomes from the TRISCEND II trial demonstrated that near elimination of TR following TTVR is associated with reduced venous congestion, RV reverse remodeling, and significant improvements in forward stroke volume and cardiac output.

• The authors present supravalvular stenosis from congenital and iatrogenic etiologies. • Multimodality imaging is essential for diagnosing supravalvular stenosis. • Echocardiography assesses severity, while CCT provides diagnostic clarity.

BACKGROUND:Buckling of a transesophageal echocardiography (TEE) probe is a rare but potentially life-threatening complication that carries a significant risk of esophageal perforation. CASE SUMMARY/METHODS:We report 3 cases of buckled TEE probes that were promptly recognized, diagnosed, and managed using multimodal imaging. In each instance, the location of the buckled probe was confirmed with bedside imaging. Subsequently, the patient was taken to the interventional suite for advancement of the probe to the stomach under fluoroscopic guidance. Finally, the buckled TEE probe was straightened and removed successfully from the patient without difficulty. DISCUSSION/CONCLUSIONS:Early recognition of buckled TEE probes and employment of a structured, algorithmic management approach are essential to optimizing outcomes and preventing associated morbidity and mortality. TAKE HOME MESSAGES/CONCLUSIONS:Buckling of the TEE probe requires a high index of suspicion and prompt diagnosis to prevent catastrophic complications such as esophageal perforation. Advancement of the TEE probe in the stomach under fluoroscopic guidance facilitates straightening and removal of the probe without the risk of esophageal perforation.

PURPOSE OF REVIEW:This review summarizes the current and evolving landscape of multimodality imaging for percutaneous endocardial left atrial appendage occlusion (LAAO) across three phases: preprocedural planning, periprocedural guidance, and postprocedural follow-up. RECENT FINDINGS:Transesophageal echocardiography (TEE) remains the primary imaging modality to assess the left atrial appendage (LAA) in all three phases of clinical care surrounding LAAO, though many innovations have led to the rise of cardiac computed tomography (CCT) and intracardiac echocardiography (ICE) as powerful adjuncts and alternatives to TEE. Advances in CCT technology such as fusion imaging and three-dimensional (3D) modeling have contributed to the emergence of CCT as an alternative to TEE for preprocedural evaluation. Intraprocedurally, real-time 3D ICE offers similar real-time guidance to TEE with similar procedural efficacy while employing a simplified workflow that can reduce procedural times and staffing needs. Post-procedural assessment with TEE or CCT is essential for evaluating device stability and complications such as peridevice leak or device-related thrombus. SUMMARY:Multimodality imaging of LAAO is a rapidly evolving field, and thoughtful integration of TEE, CCT, and ICE is critical to optimize LAAO outcomes and minimize procedural complications.

• Less-invasive interventions for moderate-to-severe, symptomatic MR are emerging. • Direct measures of MR are unreliable after intervention due to the altered orifice. • Indirect measures of MR when used together can assess procedural success. • 2D, color, and spectral Doppler indirectly evaluate MR postop. • More validation is needed to link these indirect markers to long-term outcomes.

BACKGROUND:Diagnosis and management of multivalve disease could be challenging for clinicians. Rheumatic heart disease is a well-known etiology of multivalve disease. CASE SUMMARY/METHODS:A 51-year-old male with a history of rheumatic heart disease was referred to rule out infectious endocarditis. Three-dimensional (3D) transesophageal echocardiography (TEE) showed significant stenosis of the tricuspid valve, moderate tricuspid regurgitation, rheumatic mitral valve disease, and a bicuspid aortic valve. DISCUSSION/CONCLUSIONS:Transthoracic echocardiography is the modality of choice for evaluation of cardiac valves and quantification of cardiac chambers. However, due to the complex nature of multivalve disease, using a complementary imaging technique such as 3D TEE becomes crucial in many patients. Tricuspid stenosis as the dominant valvular lesion in rheumatic heart disease is rare and almost always occurs in the presence of mitral valve disease. We present a unique case of rheumatic heart disease with the involvement of mitral and tricuspid valves in the presence of a bicuspid aortic valve, in which tricuspid stenosis is the predominant lesion. We also discuss the important role of cardiac imaging and 3D TEE in patient decision making. TAKE-HOME MESSAGES/CONCLUSIONS:Tricuspid stenosis as the dominant valvular lesion in rheumatic heart disease is rare and almost always occurs in the presence of mitral valve disease. Transthoracic echocardiography remains the modality of choice for evaluation of the tricuspid valve. 3D TEE can play an important role in reaching a final management decision.

Secondary mitral regurgitation is one of the most common valve diseases. The disease is a result of left atrial or left ventricular dysfunction. It is generally classified into stages based on its severity. While surgical intervention does not confer improved survival in this subset of mitral disease, recent advances in transcatheter interventions have resulted in improved survival and symptomatology in carefully selected patients. In this review, the multimodality imaging evaluation of the mitral valve and secondary mitral regurgitation is discussed. Commercially available and investigational transcatheter interventions for secondary mitral regurgitation management are also reviewed.

• RHD is a rare cause of severe valvular AS. • Rheumatic MS typically accompanies rheumatic AV disease. • 2D and 3D echocardiography are essential in the assessment of rheumatic AS. • CCT has become crucial in planning therapeutic procedures for AS.

PURPOSE OF REVIEW/OBJECTIVE:Although rare, the development of mechanical complications following an acute myocardial infarction is associated with a high morbidity and mortality. Here, we review the clinical features, diagnostic strategy, and treatment options for each of the mechanical complications, with a focus on the role of echocardiography. RECENT FINDINGS/RESULTS:The growth of percutaneous structural interventions worldwide has given rise to new non-surgical options for management of mechanical complications. As such, select patients may benefit from a novel use of these established treatment methods. A thorough understanding of the two-dimensional, three-dimensional, color Doppler, and spectral Doppler findings for each mechanical complication is essential in recognizing major causes of hemodynamic decompensation after an acute myocardial infarction. Thereafter, echocardiography can aid in the selection and maintenance of mechanical circulatory support and potentially facilitate the use of a percutaneous intervention.

• Paracardiac cysts (located adjacent to or inside the heart) are rarely detected. • There is a broad differential diagnosis for cysts encountered with echocardiography. • Multimodality imaging is crucial for comprehensively evaluating paracardiac cysts.