 Good afternoon. I'm pleased to present these tricuspid valve cases. Here are my disclosures. The objections of this talk will be to present cases reviewing tricuspid valve leaflet anatomy as well as to present an example of a triclip procedural assessment. So I'm first going to present some cases on leaflet identification. So this first case is a young woman who presents with fever as well as the significant past medical history of IV drug use. As you can see on these trans thoracic images, there is a mass on the tricuspid valve. So on the top row, we have an RV inflow view plus a cross plane in the short axis view. If we focus on the top left image, you can see that we can see the RV inflow view. There's the ventricular septum as well as the coronary sign is still in the picture. So we know that the leaflet to the left is going to be your septal leaflet. The leaflet on the right is your anterior leaflet and can see clearly there's a mass or vegetation there. If we look at the top right image, you can see that this is the short axis view. Now in the short axis view, if you're tilted more so you see LVOT then you're and you're seeing a single leaflet. That's the anterior leaflet. If you see two leaflets and you're looking at the anterior and posterior leaflets and you see three leaflets like you do here, you see a septal leaflet, the anterior leaflet as well as the posterior leaflet. So here there is vegetation clearly seen on both the anterior leaflet as well as the posterior leaflet. On the bottom left image is a four chamber view. Now if it's a true four chamber view with no aortic or coronary sign is visible, then it's very hard to know if you are looking at the septal and anterior leaflet or the septal and posterior leaflet. Here you can see on the every second beat we're getting a little bit of coronary sign is coming into the picture. So we know that we're a little bit posterior. So this is probably going to be septal and posterior leaflet. And you can see there's a mass on the posterior leaflet. The large vegetation on the anterior leaflet is kind of popping in and out. But it's really hard to say for sure that there's nothing on the septal leaflet. And then the bottom right image just shows the significant trigosmetric agitation that is coming through the valve. Now let's look at the trans esophageal images. So we have two sets here on the left. We are in a true mid esophageal view. We've rotated over. You see along the septum there's no visualization of the coronary sinus. And you can see a little bit of the LVOT coming in and out of plane. So you know that you're anterior. So then this is going to be your septal and anterior leaflets. And then you can see that down below with the matching color image, there's a single jet coming from the commissure. If you look on the right low images, we're now in the lowest esophagus. We've pushed the probe down a little bit. You can see coronary sinus coming in. So now we know that we are looking at anterior and posterior leaflets. And you see there's vegetations on both as well as the large perforation through the anterior leaflet. And when you look at the color image, you can see the two color jets. One represent the co-optation line and one is the perforation through the leaflet. Now we've pulled back up and we're more mid esophageal again. We're in a short axis inflow view of the right heart. And you can see we have two leaflets here. So we've both got anterior, which is more towards the aortic valve and the posterior leaflet, which is more lateral. And you see vegetations clearly on both of those, as well as the jet coming between the two of them. And on the right image, we're in a sort of off axis four chamber view. We're very posterior located because you can see the coronary sinus coming in. And so here you can see that we've got the posterior leaflet as well as the anterior leaflet and their vegetations on both of those. Now we're going down into the stomach. And these trans-castric views are actually very helpful if you can get all three leaflets in view. Here we don't really appreciate the jet because we're very, we're not located in the ideal plane to show the jet here, but you do see that there is a thickening on the anterior leaflet. So the septum tells you where the septal leaflet is, the liver tells you where the posterior leaflet is, and then by default the remaining leaflet is your anterior leaflet. Here we've actually taken a biplane and cut through the two leaflets so then you know when you're matching two chamber view, which leaflets you're looking at. So on the left series, we're cutting through the anterior and posterior leaflets and you can see the large mass on the anterior leaflet as was the perforation. And you can see a mass on the posterior leaflet. And then on the right side of image, we're cutting through the checkiest part of the anterior leaflet with the mass and a little bit of the septal leaflet. And you can see that there might be a little bit of a involvement of that septal leaflet. Here we're just getting a closer look at that anterior and posterior leaflet so you can see that there is color coming from both the perforation and the anterior leaflet as well as between the co-oputation line. One of the things you have to be aware of if you're seeing a left-sided lesion is make sure there's no sense between the two chambers. And here you can see there is a large BFO and the color is going both ways. And so this is why in some patients we close the BFO before they get a pacemaker wire in case they ever get any of those masses, ferritus masses on the pacemaker lead with time or they develop an infection of their leads. So here's the 3D taken from a distance showing the sort of destroyed nature of the tracheus favela leaflet as was the mass on that anterior leaflet. So in summary there's large vegetations on the anterior and posterior leaflets of this patient and they're as likely a minor involvement of the septal leaflet. So to follow up on this patient she was actually medically managed because of a resident IV drug use and so this shows the natural history of untreated infective endocarditis on the valve or medically managed. And you can see that the entire anterior leaflet has now been destroyed. There is a tracheus favela leaflet. The RV due to the volume load is dilated and is enlarged and you can see on the inflow view because the remodeling the cords from the septal leaflet to the wall as well as the tip are now tethering the leaflet also. So let's look at this next case. So this is a patient who is a painter who presents with chest pain and his stress test was normal in terms of ischemia. However a mass was found during the stress echocardiogram. So here's some pictures of the mass that was seen on the surface study. The leftmost image is a RV inflow view and so you see coronary sinus so you know you're looking at anterior and septal leaflet. In the short axis view on the second from the left image you were looking at the aortic valve and we see two leaflets. So you know that they're looking at that masses on the that almost looks like it should be on the posterior leaflet. But it's really hard to tell and then on the apical four chamber view once again you're you see it with every as drug sysly you see the lvot popping in so you know your anterior leaf so there's septal and anterior leaflet but here it looks more like it's once again on that septal leaflet and on the transgastric it looks again like you're on that septal leaflet. So we do a te to better localize it and get better measurements of this mass and better characterize it and so here on the leftmost image you're in a midisophageal view. You've got a four chamber we've rotated the picture over and we are seeing that it's on it appears to be on the septal leaflet okay and then on the second set of images which is a biplane through it we don't have a very clean window on the left image but the biplane shows clearly that it's attached to the septum in a true four chamber view and then we go to a dedicated four chamber view and you can see that it's right on that leaflet and we go down into the stomach if you look at the right image you can see that we're in a short axis view and you can see where the septum is in the masses right next to the septum and then we cut through it and you can see it on the long axis plane and we've actually I've tried a bigger shot of that long axis plane on the left. Here just some 3Ds to give you some better visualization of it so we are sitting in the right atrium looking down at the mass the interventricular septum is at six o'clock the semi-lunar valve is located at about the eight o'clock position so you know that the anterior is going to be leaflet is going to be on the left posterior to the right and then the septum at six o'clock and then giving you a couple of different views of this so this mass was located on the septal leaflet or anulus this patient actually was screened from a lunacy and no other masses were found he was seen by cv surgery for removal but the intervention was deferred due to stable size during follow-up on serial MRIs as well as TE and the risk of a need for pacemaker post-surgery. More recently I heard from the ascereologist follows him that he's been diagnosed with a lymphoma although the mass itself has not changed so this is briefly to review the anatomy of tricuspid valve if you're in a true midisophageal view you're looking usually at the septal and anterior leaflets if you've actually pushed down and you see the coronary sinus you're looking at the posterior and the anterior leaflets in a short axis midisophageal view you're usually and you see three leaflets you're looking at the posterior anterior and septal leaflets in a four chamber view you're looking at the septal and anterior leaflets when you go into the stomach once again the septum tells you where the septal leaflet is and then the liver is where the posterior leaflet and the remaining leaflet then is the anterior leaflet and when you cut through then you can actually appreciate which leaflets you're looking at. Now let's look at this case for triclip assessment so this is an 83-year-old female who has a history of bypass surgery she was found to have severe tricuspid regurgitation with increased RV size and was referred for triclip so is she a candidate so first we do our first images when we're assessing looking at the source of the jet here we're in the transcatric views once again we want to make sure that we can see where the origin of the jet is and we want to know if it's really between the anterior and septal leaflets or the posterior and septal leaflets because those are where we place our clips we do not place them between the anterior posterior leaflet because there's no view for us to double check the placement on that most of the times you'll find that the jets are most patients of secondary tr and so the jets are central but what we need is we need to find out if we can move from the commissures towards the body of the leaflets and if patients have a pacemaker leader that does not preclude them from getting a clip procedure we just want to now in this view see where the lead is going and make sure that there is jet that is an area different from where the pacemaker lead is we try not to jail the leads if we don't have to so we do a series of images in the transcastric views where we cut through the anterior posterior leaflet the um and we essentially locate the um locate the color and we then take color off take the 2d image and then take the color image and what we want to do is we want to see that we can see the where the jet is coming from and what the views look like in this view so in this patient they've got a large central jet but they do have jet coming from between the posterior and septal leaflets as well as the anterior and septal leaflets now we come up to the midisophageal or lowisophageal views and we go to a short axis view and here we want to see the rv in flow outflow and what we want we're a little off axis here but this is the way we could get the views because the rv enlargement and we want to see three leaflets we want to see the uh posterior leaflet which is the left most and then the anterior leaflet in the middle and the septal leaflet along the septum and we cut through we put the color on we see where the jet is and we cut through each of these leaflets with the biplane with and without color to localize the jet so the left is how we deliver the device and know that we are placing it properly and aligning ourselves properly the biplane that cuts through usually gives you a reverse four chamber view which lets us know if we're delivering the device properly and we want to know what the gap is okay so that's why we do these series of views once we have that then we actually try and get these true sort of four chamber views because this is how we're going to look at to place the clips and we want to know that the gap between the two leaflets is less than seven millimeters we also want to make sure that the septal leaflet is more than a centimeter in order to grab and it's not too curled or that there are no cords in the area where we're planning to clip because those can actually impede our ability to get under the leaflet and to grab it so here on the top you've got the posterior and anterior leaflets because you see coronary signage which is very dilated and you see there's a jet there and then we've got on the right row a true four chamber view with no coronary signs visible so you know that this is septal and anterior leaflet there and you see there's jet everywhere so that gives us a couple of options for placing the clip we also do the reverse four once again to look at the gaps as well to look at any septal leaflet pathology 3d echocardiography is very important it's much more challenging to get 3d trecus with valve images than compared to trans thoracic images but here I've orange at the top the left and the middle images in the sort of the ac guideline way with the septum at six o'clock and then if you know where your semi-lunar valve is so here we're looking from a from a right atrial view so you can see this sorry a bright particular review so you can see that the rv outflow tract is to your four o'clock position and so then the anterior leaflet is at one o'clock and then you're posterior leaflets about nine o'clock in your septal leaflets at six o'clock and then you've got the color jet and you can see the color jet running up the septum there and then here there's a push for a lot of the interventional echocardiographers to reorient how we position the trecus bed valve and what they really want to do is put the aortic valve or the outflow tract at about one o'clock so then your septum is at about three o'clock to see um to orient better for the procedure so this patient was accepted and uh the here's some images from the procedure so here if the an image a you can see that we're bringing the clip in we're in that inflow outflow view we've got the three leaflets where we want to go is where the star is and so this is how we bring the clip in we want to first before we dive in make sure our clip is oriented in a direction that we want because we don't want to make a lot of movements once we're in the ventricle because we don't want to get caught up in the cords so if you look at image b we're a little really off plane here and then if you look at image c we're right over the septal and anterior commissure and then if you now we're in the RV if you look at image a we've pushed into the right ventricle we're now we've kind of pushed when we pushed in moved a little bit more medial than um then we had planned so what we do is we go into the trans gastric views once again we get that those visualization of three leaflets we can see the um the orientation of the clip is not exactly perpendicular to the co-optation line between the anterior and the septal leaflets so we um rearrange ourselves if you look at the 3d image on panel c you can see that we're reorienting a little bit better along the co-optation line and then when we come back up to the midisophageal views you can see that in image d we're actually close to that septal leaflet you can see where we are and you can see that we are um that's a picture of us closing the clip and we can see both the anterior um sorry this anterior and the septal leaflets lying on the clip nicely as we close and that um we have a good grab there so this picture shows that first clip we still have a little bit of tricuspid regurgitation uh but we can see that it's holding on nicely even if the um we don't reduce the the jet a lot this first clip actually serves and is the sort of an annual plastic to bring the valve in a little bit and makes it easier for us to get the other clips on later on so now we're going to because we have residual regurgitation we're going to put a second clip on so uh in panel a here we're reorienting above the clip above the first one we're going to put the second clip right um next to the first one grabbing both the um anterior and the septal leaflets again we once again if you look at panel b we dive in once we've oriented ourselves and now we're going to try and bring it up and grab it and on panel c you can see the leaf uh the clip closing um there's a lot more artifact now now that we have that first clip in so between the instrumentation as well as the first clip there's a lot more artifact the picture's become a little bit tougher uh with the second clip and you can see we were able to place a second clip on image d now we go back into the stomach we check the to make sure that the leaflets are really tightly into that clip and you can see on image um on the left image there uh we've got that anterior leaflet going into the clip as we sweep through and there's color but there's still color coming above it um the clip more centrally um and we can see that there's color coming around it on the rightmost image if we when we go back into the mid soft gel picture so now we're going to try and place a third clip to get further reductions try cuspid regurgitation but instead of going between the septal and anterior leaflets we're going to go between the septal and posterior leaflets so the uh 3d image on the left we're positioning our clip orientation to make sure that it's going to be as a perpendicular to co-optation as we can get and then on the right you can see some of the challenges with the imaging here um we go down into the um ventricle here and we're trying to close the clip if you look at that biplane you can see the clip closing as it goes uh place through the clip but the problem is even though we can see where the um posterior leaflet is or is being grabbed uh we or the septal leaflet is being grabbed we really can't see that anterior due to shadowing from the device and so that makes it really challenging to place it and so because we couldn't be confident of that grab we actually um did not place a third clip in this patient so in the end uh though the patient had significant improvement in their clinical function and was doing well um their TR was reduced and um and they were uh very happy with the procedure six months after uh it was performed thank you for listening