Heart 3D: Echocardiographic and Anatomical Features of the Tricuspid Valve in a Heterogeneous Population with Severe Regurgitation-Implications for Edge-to-Edge Procedure Suitability

Jan Sobieraj^1,2*Adam Rdzanek^1*Agnieszka Kapłon-Cieślicka¹Zenon Huczek¹Mariusz Tomaniak¹Ewa Ostrowska^1,2Adam Piasecki^1,2Ewa Pędzich¹Scisło Piotr¹

• ¹1st Department of Cardiology, Medical University of Warsaw, Warsaw, Poland
• ²Medical University of Warsaw, Doctoral School, Warsaw, Poland

Aim: To assess the incremental value of real-time three-dimensional (3D) transesophageal echocardiography (TEE) in visualizing tricuspid valve (TV) anatomy for procedural planning and guidance of transcatheter edge-to-edge repair (TEER) in severe tricuspid regurgitation (TR). Materials and methods: An observational study was conducted in 54 patients with severe TR. Visualization of the TV leaflets during systole was semi-quantitatively graded using predefined criteria: 0 points – no visible leaflet border or tissue; 1.25 – border only; 2 – border and <50% tissue; 3 – border and >50% tissue. Each of the three leaflets was evaluated independently in both 2D and 3D TEE, with a cumulative maximum score of 9. Two thresholds were established: ≥4.5 points as the primary endpoint for adequate visualization for TEER planning, and ≥6 points as the secondary endpoint indicating sufficient quality for detailed morphological assessment. Results: In 3D TEE, 77.8% of patients achieved the primary endpoint, and 68.5% reached the secondary threshold. In comparison, 2D TEE enabled 74.1% and 42.6% of cases to meet these respective thresholds. Although the difference in achieving the primary endpoint was not statistically significant (p = 0.82), 3D TEE significantly outperformed 2D in enabling detailed morphological evaluation (p = 0.012). No significant differences were noted in the visualization quality of the anterior versus septal leaflets with 3D TEE (67.4% vs. 65.4%, p = 0.800). For the posterior leaflet, 3D TEE provided superior visualization compared to 2D (p = 0.0008), while still supporting procedural suitability in a comparable proportion of cases (85.4% vs. 89.8%, p = 0.400). Acoustic shadowing from the interatrial septum and aortic root accounted for 92% of inadequate visualizations. Conclusion: In this observational study, real-time 3D TEE proved feasible for assessing tricuspid valve anatomy and visualization quality in patients with severe TR considered for TEER. Compared to 2D TEE, 3D TEE offered improved visualization of the posterior leaflet and provided adequate image quality for procedural planning in most cases. Moreover, a statistically significant advantage was observed for 3D TEE over 2D TEE in providing image quality sufficient for detailed morphological evaluation.