Interest in transcatheter treatment of tricuspid regurgitation (TR) has grown significantly in recent years due to increasing evidence correlating TR severity with mortality and to limited availability of surgical options often considered high-risk in these patients. Although edge-to-edge repair is currently the main transcatheter therapeutic strategy, tricuspid valve direct annuloplasty can also be performed safely and effectively to reduce TR and improve heart failure symptoms and quality of life. In the annuloplasty procedure, an adjustable band is implanted around the tricuspid annulus to reduce valvular size and improve TR. Patient selection and careful preoperative imaging, including transthoracic echocardiography, transesophageal echocardiography, and computed tomography, are critical for procedural success and proper device implantation. Compared to edge-to-edge repair, perioperative imaging with transesophageal echocardiography and fluoroscopy is particularly challenging. Alignment and insertion of the anchors are demanding but essential to achieve good results and avoid damaging the surrounding structures. The presence of shadowing artifacts due to cardiac devices makes the acquisition of good-quality images even more challenging. In this review, we discuss the current role of multimodality imaging in planning direct transcatheter tricuspid valve annuloplasty and describe all procedural steps focusing on echocardiographic monitoring.

Multimodality imaging approach in planning and guiding direct transcatheter TV annuloplasty. Colored boxes summarize the role in preprocedural anatomofunctional assessment and intraprocedural guidance of each imaging strategy, as well as the role of multimodality imaging in evaluating final results. Echocardiography is the first key imaging tool that allows for a comprehensive evaluation of TV and TA anatomy, TR etiology and severity, and RV size and function. Three-dimensional TEE also permits careful preprocedural planning of device sizing and first anchor positioning. Computed tomography is crucial for planning the full anchorage and assessing RCA distance from TA. Anchor deployment is fully imaged at echocardiography, while fluoroscopy mainly helps in assessing CIED interaction with the delivery system, as well as RCA distance from the anchors. All anchors should be positioned very close to the HPs of TV leaflets and require the IC to be carefully orientated with specific angles with respect to TA. During and after band contraction, TEE monitors gradual TR reduction and final results, including new TA dimensions and RV size and function. Both echocardiography and fluoroscopy are helpful for detecting early postprocedural complications, including pericardial effusion and RCA impingement. (A) Assessment of TR severity by quantification of vena contracta (VC) 3D. (B) Measure of TA perimeter and the distance between the planned position of the first anchor and the center of the aortic valve through 3D TEE and MPR tool. (C) Correct alignment of the IC with respect to the TA during fourth anchor positioning shown at 3D TEE. (D) The angle between the IC and the TA plane should be approximately 45° on the radial plane (left panel) and 90° on the tangential plane (right panel). (E-F) Preprocedural versus postprocedural (5.5 cm of band contraction) TR severity at color-flow mapping. AV, Aortic valve; MDCT, multidetector CT; PA, pulmonary artery; sPAP, systolic pulmonary artery pressure.