Transcatheter heart interventions are expanding, and structural procedures are becoming more complex. This makes detailed visualisation and characterisation of cardiac anatomy and pathology increasingly important. As a result, there is a growing interest in interventional imaging for procedural guidance. Specifically, there is an increasing interest in using intracardiac echocardiography (ICE) as a complementary or alternative tool to transoesophageal echocardiography. Furthermore, new-generation three-dimensional matrix array ICE probes provide the possibility of obtaining multiplanar reconstruction imaging, playing a crucial role in structural heart interventions. To date, we still need guidelines that summarise the technical details of the most used ICE probes and that standardise procedure protocols. The purpose of this expert review is to provide an overview of ICE technology, describe the technical characteristics of the available probes, and present a review by a group of experts on their use in guiding structural heart interventions based on global clinical experience.

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: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. (EVOQUE Transcatheter Tricuspid Valve Replacement: Pivotal Clinical Investigation of Safety and Clinical Efficacy Using a Novel Device [TRISCEND II Pivotal Trial]; NCT04482062).

INTRODUCTION:Severe tricuspid regurgitation (TR) is common, undertreated, and associated with significant morbidity and mortality. Transcatheter tricuspid valve replacement (TTVR) has emerged as a promising option for patients unsuitable for surgical repair or transcatheter edge-to-edge repair. AREAS COVERED:This review examines the innovation trajectory, current device landscape, patient selection, imaging guidance, procedure-specific challenges, and future perspectives of TTVR. A systematic literature search was performed using PubMed/MEDLINE, Embase, and ClinicalTrials.gov, covering publications from January 2015 to May 2025, using search terms including 'transcatheter tricuspid valve replacement,' 'TTVR,' 'tricuspid regurgitation,' and device-specific names. EXPERT OPINION:TTVR offers near-complete regurgitation elimination but remains anatomy- and mechanism-dependent. Its role is best defined in patients with anatomy unfavorable for repair. Optimal timing, device selection, antithrombotic management, and long-term durability require prospective validation through dedicated trials and head-to-head comparisons with repair strategies.

BACKGROUND:The impact of proportionality to heart valve regurgitation has been widely investigated in mitral regurgitation, helping to better characterize the best candidates for therapies. However, it has never been studied in tricuspid regurgitation (TR). The aim of the present study is to investigate the impact of the proportionality of TR on outcomes. METHODS:Patients undergoing tricuspid transcatheter edge-to-edge repair were selected from the TRIVALVE registry (International Multisite Transcatheter Tricuspid Valve Therapies Registry). Patients were divided according to the ratio between effective regurgitant orifice area (EROA) and right ventricular (RV) end diastolic diameter (RVEDD) into tertiles: patients with low EROA/RVEDD (RV, dominant); intermediate EROA/RVEDD (RV and TR, RV-TR, codominant), and high EROA/RVEDD (TR, dominant). The primary outcome was all-cause mortality. Median follow-up was 9.7 months (4.2-12.0). RESULTS:A total of 204 patients were included in the present study: 67 for the RV dominant, 68 for the RV-TR codominant, and 69 for the TR dominant group. The 3 groups presented different baseline characteristics. Survival analysis among the 3 groups showed a trend towards worse prognosis for the RV-dominant group, as compared with the RV-TR codominant and TR dominant groups. CONCLUSIONS:The conceptual framework of proportionality is applicable to TR with EROA/RVEDD, defining a higher risk RV-dominant phenotype with a trend towards worse survival after tricuspid transcatheter edge-to-edge repair.

AIMS:To assess the association between right heart failure (RHF) and mortality in patients with severe tricuspid regurgitation (TR) undergoing transcatheter tricuspid valve intervention (TTVI), and to determine whether clinical RHF status reduces the survival benefit of successful versus failed TTVI. METHODS AND RESULTS:The TriValve International Registry (Transcatheter Tricuspid Valve Therapies) is a multicenter registry collecting data of patients with symptomatic, severe or greater TR undergoing TTVI. The population was stratified according to RHF status defined by the following clinical criteria: history of previous hospitalization for RHF (<1 year) OR presence of signs of RHF (jugular venous distension, ascites, peripheral oedema) OR high dose diuretic (≥125 mg/day of furosemide or equivalent). The outcome of interest was 1-year all-cause death. Among 639 patients included in the TriValve registry, 498 had complete data regarding RHF status. Overall, 54 (10.8 %) patients had no criteria for RHF, 133 (26.7 %) patients fulfilled 1 criterion, 240 (48.2 %) 2 criteria and 71 (14.3 %) 3 criteria. At a median follow-up of 216 days (IQR 49-372 days), cumulative incidence of all-cause death was higher in patients with 2 or 3 RHF criteria versus those with no or 1 RHF criterion (adjusted HR 2.91-95 % CI 1.46-5.83, P = 0.002). However, RHF status did not influence the association between procedural success and all-cause death at 1-year follow-up (p for interaction 0.857). CONCLUSIONS:In a large real-world population undergoing TTVI for severe TR, the presence of at least 2 RHF clinical criteria was independently associated with an increased risk of 1-year mortality. Procedural success was associated with a lower risk of mortality regardless of RHF status.

The transcatheter EVOQUE tricuspid valve replacement system is an approved device for the treatment of patients with symptomatic severe tricuspid regurgitation despite medical therapy both in the United States and in Europe. Specific imaging requirements are needed in the screening and in the intraprocedural phase as well as to assess this valve after implantation, in order to assess its positioning and performance. In this review, focus will be on the postoperative echocardiographic assessment of device positioning and stability; evaluation of residual central tricuspid regurgitation or paravalvular leak; valve thrombosis/degeneration; interaction of the device frame with the right ventricle and adjacent structures, including the aortic valve and interventricular septum; and placement of pacemaker leads. This review will therefore be centered on these essential imaging aspects in the echocardiographic postimplantation evaluation of the EVOQUE valve.

Despite a plethora of pharmacological therapies for heart failure (HF), reducing the symptomatic burden in patients with advanced HF remains an unmet clinical need. Over the past decade, atrial shunting has emerged as a novel therapy for those with symptomatic HF despite optimal guideline-directed medical therapy. Initially thought of as a therapy reserved for those with diastolic HF, the field now spans the entire HF spectrum. In this review, we explore the physiology, devices, and trials that have shaped the field of atrial shunting. We detail how device-based interatrial shunts, no-implant interatrial shunts, and coronary sinus shunts aim to provide clinical benefit in specific patient populations and the limitations associated with their use.

Background Valvular heart disease (VHD) is a major focus of cardiovascular medicine, but limited data are available for racial and ethnic minorities. The aim was to assess the burden and clinical correlates of VHD in a highly diverse area of the United States. Methods and Results Individuals with echocardiographic diagnosis of native VHD between January 2010 and December 2019 at a quaternary care health system of the Bronx (New York, USA) were included. Prevalence and correlates of VHD were assessed per each racial and ethnic group. From a total of 330 570 adult echocardiograms, 80 584 individuals were diagnosed with VHD and included in the final study population. Stratified by race and ethnicity, 38.0%, 23.2%, 2.1%, and 36.7% were non‐Hispanic Black, non‐Hispanic White, Asian, and Hispanic, respectively. The mean age was 67.7±16.3 years, with non‐Hispanic Black, non‐Hispanic Asian, and Hispanic individuals being younger and having a higher burden of comorbidities. The prevalence of VHD increased with age, irrespective of race or ethnicity. In people aged ≥75 years, tricuspid and mitral regurgitation were the most prevalent VHD (21.1% and 16.1%, respectively). Non‐Hispanic White individuals more frequently had tricuspid regurgitation, mitral regurgitation, and multiple VHDs, but among those aged <65 years, these were more frequent in non‐Hispanic Black individuals. Conclusions Our Bronx‐Valve Registry illustrates that the burden of VHD is high, increases with age, and varies among racial and ethnic groups. When diagnosed with VHD, non‐Hispanic Black, non‐Hispanic Asian, and Hispanic individuals are younger and with a higher burden of comorbidities. Appropriate resources and strategies need to be implemented to minimize racial and ethnic disparities and promote equity in VHD diagnosis and cardiovascular risk factor management. Registration URL: https://clinicaltrials.gov . Unique Identifier: NCT05453526.

Robotics entered the cardiovascular field in the late 1990s with a robot-assisted coronary artery bypass graft. Since then, the use of robots has become a common part of cardiovascular surgery in several types of interventions. The experience in transcatheter interventions has been slower, and the application of robotics to percutaneous coronary interventions has shown some encouraging results but also some technical limitations. Following the growth of structural heart interventions, attention has recently switched to the potential application of robotics in this field. So far, several cases have been performed in animal models and only a few cases in humans. The opportunity to perform a procedure (almost) without any X-ray exposure or lead garments is extremely attractive, especially for operators. Alongside these, there are several further potential advantages, but there are also many challenges to overcome. The integration of artificial intelligence and machine learning in the near future might further contribute to improve the performance of future generations of robots. In this review, the current and future applications of robotics in structural heart interventions and transoesophageal echocardiography will be discussed, together with the potential advantages, challenges and future perspectives.

Current guidelines of aortic stenosis (AS) management focus on valve parameters, LV systolic dysfunction, and symptoms; however, emerging data suggest that there may be benefit of aortic valve replacement before it becomes severe by present criteria. Myocardial assessment using novel multimodality imaging techniques exhibits subclinical myocardial injury and remodeling at various stages before guideline-directed interventions, which predicts adverse outcomes. This raises the question of whether implementing serial myocardial assessment should become part of the standard appraisal, thereby identifying high-risk patients aiming to minimize adverse outcomes.

Introduction: The proximal isovelocity surface area (PISA) method has been validated for quantifying severity of mitral regurgitation (MR) in orifices with circular geometry. However, functional MR often has an elliptical orifice, which alters the proximal isovelocity contour from a hemisphere to a hemi-ellipsoid. Studies have previously shown that PISA underestimates regurgitant flow (RF) and effective regurgitant orifice (ERO) in functional MR. Hypothesis: The application of a simplified hemi-ellipsoid formula based on biplane color Doppler improves accuracy in calculating RF and ERO across elliptical orifices. Methods: An in vitro model for flow quantification was used for all experiments. Multiple size orifices with minor to major ratios ranging from 1:1 to 1:9 were constructed by 3D printing. Flow was adjusted at multiple intervals to generate peak flow velocities ranging from 4.1 to 5.5 m/s and aliasing velocities from 12 to 18 cm/s. Isovelocity contours were evaluated by biplane color Doppler (Figure 1A). RF and ERO were estimated using the traditional hemispheric PISA (HS-PISA) formula and a simplified hemiellipsoid formula (HE-PISA) based on two orthogonal diameter measurements (Figure 1A and 1B). The estimated RF and ERO values were compared and validated against those derived from a magnetic flowmeter (FM). Results: Isovelocity contours changed from hemisphere to hemi-ellipsoid orifices with increasing ellipticity ratios. HS-PISA significantly underestimated RF (116 ± 27 vs FM 155 ± 20 ml/s) and ERO (26 ± 4 vs FM 34 ± 1 mm 2 ). Underestimation was significantly reduced by HE-PISA (135 ± 17 ml/s and 30 ± 2.5 mm 2 , both p<0.001). Conclusions: A simplified hemi-ellipsoid PISA method provides more accurate assessment of RF and ERO in regurgitant orifices with non-circular geometries.

BACKGROUND:Transcatheter aortic valve replacement (TAVR) for aortic stenosis (AS) is increasingly performed in younger patients with long life expectancy. However, limited data exist on the durability of transcatheter heart valves (THVs). AIMS:The aim of the present work is to compare the long-term durability of balloon-expandable (BEV) and self-expanding (SEV) THVs after TAVR. METHODS:Electronic databases were searched up to May 2025 for studies reporting on the long-term durability of THVs in patients undergoing TAVR with a minimum follow-up of 5 years. Pooled odds ratios (ORs) with 95% confidence interval (CI) were used as summary statistics and were calculated using a random-effects model. Co-primary endpoints were moderate and severe structural valve deterioration (SVD) and the occurrence of all-cause bioprosthetic valve failure (BVF). All-cause death was the secondary endpoint. RESULTS:A total of 22 studies and 12,131 patients undergoing TAVR were included: 52.5% of patients (n = 6362) received BEV, 47.5% (n = 5769) SEV. An old-generation THV was used in 84.5% of cases. At a median follow-up of 7 (5-8.3) years, the overall pooled estimates of moderate/severe SVD and BVF were 7% (5-9) and 4% (3-5), respectively. Patients treated with a BEV experienced a higher rate of SVD (OR: 2.09; 95% CI: 1.58-2.75; p < 0.001) and BVF (OR: 1.61; 95% CI: 1.10-2.36; p = 0.014); no difference was observed in terms of all-cause death. CONCLUSIONS:At long-term follow-up after TAVR, patients receiving a BEV experienced higher rates of moderate/severe SVD and of BVF compared to those having a SEV. However, no significant differences between the two THV designs were observed on the clinical endpoint of all-cause death.

Paravalvular leak (PVL) following transcatheter aortic valve replacement (TAVR) is an established complication, albeit rarely associated with hemolytic anemia. This report details 3 cases of significant hemolytic anemia attributed to TAVR-induced PVL, each with distinct clinical presentations and manifestations. These cases underscore the diverse and occasionally subtle clinical presentation of aortic PVL-associated hemolytic anemia. We explore the technical nuances and challenges of percutaneous PVL closure and emphasize the successful resolution of hemolytic anemia by using percutaneous PVL plugging with occluder devices. Through this case series, we encourage the awareness of PVL-associated hemolytic anemia in the differential diagnosis of patients presenting with new onset anemia after TAVR and demonstrate the efficacy of percutaneous closure techniques in resolving this serious condition.

BACKGROUND The CLASP IID randomized trial (Edwards PASCAL TrAnScatheter Valve RePair System Pivotal Clinical Trial) demonstrated the safety and effectiveness of the PASCAL system for mitral transcatheter edge-to-edge repair (M-TEER) in patients at prohibitive surgical risk with significant symptomatic degenerative mitral regurgitation (DMR). OBJECTIVES This study describes the echocardiographic methods and outcomes from the CLASP IID trial and analyzes baseline variables associated with residual mitral regurgitation (MR) <= 1+. METHODS An independent echocardiographic core laboratory assessed echocardiographic parameters based on American Society of Echocardiography guidelines focusing on MR mechanism, severity, and feasibility of M-TEER. Factors associated with residual MR <= 1+ were identified using logistic regression. RESULTS In 180 randomized patients, baseline echocardiographic parameters were well matched between the PASCAL (n = 117) and MitraClip (n = 63) groups, with flail leaflets present in 79.2% of patients. Baseline MR was 4thorn in 76.4% and 3+ in 23.6% of patients. All patients achieved MR <= 2+ at discharge. The proportion of patients with MR <= 1+ was similar in both groups at discharge but diverged at 6 months, favoring PASCAL (83.7% vs 71.2%). Overall, patients with a smaller flail gap were significantly more likely to achieve MR <= 1+ at discharge (adjusted OR: 0.70; 95% CI: 0.50-0.99). Patients treated with PASCAL and those with a smaller flail gap were significantly more likely to sustain MR <= 1+ to 6 months (adjusted OR: 2.72 and 0.76; 95% CI: 1.08-6.89 and 0.60-0.98, respectively). CONCLUSIONS The study used DMR-specific echocardiographic methodology for M-TEER reflecting current guidelines and advances in 3-dimensional echocardiography. Treatment with PASCAL and a smaller flail gap were significant factors in sustaining MR <= 1+ to 6 months. Results demonstrate that MR <= 1+ is an achievable benchmark for successful M-TEER. (Edwards PASCAL TrAnScatheter Valve RePair System Pivotal Clinical Trial [CLASP IID]; NCT03706833) (J Am Coll Cardiol Img 2024;17:471-485) (c) 2024 by the American College of Cardiology Foundation.