Author + information
- Received August 3, 2018
- Revision received September 14, 2018
- Accepted September 25, 2018
- Published online December 17, 2018.
- Austin A. Robinson, MDa,∗ (, )
- Kimberly Chadwell, RDCSa,
- Dale E. Fowler, MD, RDCSa,
- Gorav Ailawadi, MDa,b and
- D. Scott Lim, MDa,b
- aHeart and Vascular Center, University of Virginia, Charlottesville, Virginia
- bAdvanced Cardiac Valve Center, University of Virginia, Charlottesville, Virginia
- ↵∗Address for correspondence:
Dr. Austin A. Robinson, University of Virginia Health System, 1215 Lee Street, Charlottesville, Virginia 22908.
A 79-year-old man with a history of long-standing atrial fibrillation and surgical annuloplasty for mitral valve prolapse presented with ascites and lower extremity edema refractory to diuretics and serial paracenteses. Transthoracic echocardiography confirmed the presence of severe tricuspid regurgitation, but he was deemed to be at prohibitive risk for surgical repair because of frailty. He was thought to be a suitable candidate for percutaneous edge-to-edge repair of his tricuspid valve, but transesophageal echocardiography (TEE) images were of low quality (Figure 1). Conventional intracardiac echocardiography (ICE) provided good acoustic definition but did not allow for multiplane angulation necessary to ensure precise clip placement.
A novel approach was devised to enable multiplane-capable ICE. The right internal jugular vein was accessed percutaneously and sheath upsized to a 26-F catheter Dryseal sheath (Gore, Flagstaff, Arizona). Through this a S8-3T MicroTEE echocardiography probe (Philips, Amsterdam, Netherlands), in a sterile sleeve (CIV-Flex Transducer Cover #610-1013, CIVCO, Coralville, Iowa), was advanced to the right atrium (Figures 2 and 3⇓⇓). This allowed ICE capable of 180-degree image plane control (Figure 4, Online Video 1). Transcatheter tricuspid valve repair was performed using MitraClip system (Abbott Vascular, Santa Clara, California) (Figure 5, Online Video 2). We implanted 3 clips: 2 on the septal-anterior commissure and 1 on the anterior-posterior commissure, with reduction of tricuspid regurgitation from severe to mild. Right atrial pressure was reduced from 18 to 13 mm Hg. The mean tricuspid inflow gradient post-clip was 1 mm Hg.
Building on techniques of epicardial echocardiography, our probe was contained within a sterile sleeve, along with sterile coupling gel (Aquasonic 100 ultrasound gel, # 01-01, Parker Labs, Fairfield, New Jersey). The probe underwent high-level disinfection using a standard TEE probe reprocessor bath (ASTRA automated reprocessor, CIVCO) and o-Phthaladehyde-containing disinfectant (Cidex OPA, Advanced Sterilization Products, Irvine, California). In the event of sleeve rupture, infectious risk to the patient should be low. There are no data on the risk of intravascular disinfectant exposure from the probe itself, but no adverse effects have been noted with oral doses up to 5 mg/kg/day (1). Furthermore, the amount of disinfectant residue on the probe is expected to be negligible, given published evaporation rates.
Percutaneous tricuspid interventions can be feasibly guided by intravascular placement of narrow-width TEE probes via the internal jugular vein. This novel ICE configuration allows for multiplane imaging and full Doppler interrogation to guide structural interventions, in closer proximity and with higher quality visualization of the tricuspid valve than conventional TEE.
Dr. Ailawadi is a consultant for Medtronic, Edwards Lifesciences, Abbott, and Mitralign. Dr. Lim has received research grants from Medtronic, Edwards Lifesciences, Abbott, LivaNova, and Gore. Dr. Robinson was supported by National Institutes of Health grant T32EB003841. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 3, 2018.
- Revision received September 14, 2018.
- Accepted September 25, 2018.
- 2018 American College of Cardiology Foundation
- ↵CIDEX OPA Concentrate Material Safety Data Sheet, September 2010. Available at: https://www.hopkinsmedicine.org/hse/forms/cidexopa/OPA_MSDS.pdf. Accessed September 13, 2018.