3D Echocardiographic Characteristics of the GATE™ Tricuspid Valved Stent Implanted Using the Transjugular Approach

by Luigi P. Badano, MD, PhD; Claudia Colombo, MD; Denisa Muraru, MD, PhD.
Department of cardiac, thoracic and vascular sciences, University of Padua, School of Medicine, Padua, Italy

Clinical Case

  • Male, 67 yrs old.
  • 1990 – Heart transplant
  • 2016 – Admitted for heart failure
  • Echocardiography: severe tricuspid regurgitation, dilated tricuspid annulus. Normal left ventricular function, mild mitral regurgitation

2D echocardiography right ventricular focused apical 4-chamber view showing dilated tricuspid annulus (44 mm) and severe tricuspid regurgitation. Both atria are severely dilated

3D echocardiography quantitation of tricuspid annulus using custom software package confirming severe enlargement of major and minor axes of the tricuspid annulus (49 mm and 46 mm, respectively) and 3D annular area= 21.3 cm2

During Heart Team discussion it was given indication to percutaneous tricuspid valve prosthesis implant.

A GateTM Tricuspid Stented Valve was succesfully implanted using the transjugular approach. The procedure was uneventful.

Conventional 2D echocardiography (left panel) and bi-plane (right panel) visualization of the prosthetic valve in tricuspid position. Both the stent (white arrows) and the leaflets are well visualized
Abbreviations: LA, left atrium; LV, left ventricle; RA, right atrium; RV, right ventricle; RVOT, right ventricular outflow tract

Three-dimensional transversal cut plane of the tricuspid prosthetic valve visualized from the right ventricular perspective. The stent (white arrow) and the 3 valve leaflets (A, anterior; P, posterior; and S septal) are clearly visualized. On the right panel, 3 dimensional color Doppler full-volume showing mild intra- and para- prosthetic leaks (/red arrows)
Abbreviation: MV, mitral valve

The 3D data set can be sliced in multiple 2D views (12 slice mode) and the slices oriented parallel to the position of the prosthesis in order to obtain properly oriented short axes view of the prostetic valve (asterisks) to appreciate the shape of the stent and the motion of the leaflets

Key messages

2D/Doppler echocardiography enabled:

  • Single diameter estimation of tricuspid annulus size
  • Visualization of the prosthesis and of two leaflets
  • Color Doppler assessment of regurgitant flow
  • Transprostetic mean gradient (2 mm Hg)

3D echocardiography allowed:

  • Comprehensive and anatomically sound quantitative assessment of tricuspid annuls size and shape
  • En face vie of the prosthesis from both atrial and ventricular perspectives
  • Identification of number and sites of regurgitant jets
  • Quantitative assessment of right ventricular and atrial volumes independent on geometric assumptions

References:

  1. Muraru D, Veronesi F, Maddalozzo A, Dequal D, Frajhof L, Rabichowsky A, Iliceto S, Badano LP. Three­dimensional printing of normal and pathologic tricuspid valves from transthoracic three­dimensional echocardiography data sets. Eur Heart J Cardiovasc Imaging 2017 18 (7): 802-808
  2. Muraru D, Bidviene J, Cavalli G, Cavaliere A, Badano LP. Tricuspid regurgitation in a patient with ascending aorta aneurysm. Eur Heart J Cardiovasc Imaging. 2016;17(12):1435
  3. Muraru D, Surkova E, Badano LP. Revisit of functional tricuspid regurgitation; Current trends in the diagnosis and management. Korean Circulation Journal 2016; 46(4):443-55
  4. Addetia K, Muraru D, Veronesi F, Jenei C, Cavalli G, Besser SA, Mor-Avi V, Lang RM, Badano LP. Three-dimensional Echocardiographic Analysis of the Tricuspid Annulus Provides New Insights into Normal Tricuspid Valve Geometry and Dynamics. JACC Cardiovasc Imaging 2017 (in press)
  5. Taramasso M, Pozzoli A, Guidotti A, et al. Percutaneous tricuspid valve therapies: the new frontier. Eur Heart J 2017; 38: 639-47