Early Experience with Acuson AcuNav 4D-ICE to Guide Transcatheter Tricuspid Edge-to-Edge Repair: 4D Intracardiac Echocardiography Compared to Transesophageal Echocardiography

Tricuspid regurgitation is a common valvular disease associated with high morbidity and mortality if left untreated. While surgery has been the standard intervention, transcatheter tricuspid edge-to-edge repair (T-TEER) has emerged as an alternative for high-risk surgical candidates. Transesophageal echocardiography (TEE) is the gold-standard imaging modality for guiding T-TEER due to its high spatial and temporal resolution. However, it requires general anesthesia and esophageal intubation, limiting its use in certain patients. Additionally, TEE image quality may be compromised by anterior structure shadowing, which is common in T-TEER. The development of 4D intracardiac echocardiography (ICE) offers real-time, three-dimensional imaging, potentially overcoming these limitations. This study compared TEE and Acuson AcuNav 4D-ICE in guiding T-TEER in ten high-risk patients across eight crucial procedural steps. ICE showed optimal feasibility in key procedural steps, including valve steering and leaflet grasping, due to its proximity to target structures, minimizing shadowing artifacts. Both modalities performed equally in lesion identification and residual regurgitation assessment and achieved non-statistically different results in most quantitative measurements. This study supports the integration of 4D-ICE into T-TEER procedures, particularly for patients unsuited for TEE or with complex TEE windows. Its real-time imaging, reduced invasiveness, and feasibility in critical steps highlight its potential as a viable alternative or complement to TEE. Further multicenter studies are needed to validate its role, optimize protocols, and evaluate long-term outcomes in 4D-ICE-guided T-TEER.