Automated 3D echocardiography vs computed tomography for TTVR screening: a prospective single centre study

Abstract Background Transcatheter tricuspid valve replacement (TTVR) is a promising treatment for patients with severe tricuspid regurgitation at high surgical risk. Accurate anatomical evaluation is essential for procedural planning. Although cardiac computed tomography (CCT) is the current gold standard, the diagnostic performance of three-dimensional transthoracic (3D-TTE) and transoesophageal echocardiography (3D-TOE), particularly when combined with automated annulus assessment, remains incompletely defined. Purpose To prospectively evaluate the feasibility and diagnostic agreement of 3D-TTE and 3D-TOE with CCT in assessing anatomical suitability for TTVR, using a novel artificial-intelligence (AI) powered automated tool (3D Auto TV ) for tricuspid valve annulus (TVA) and subvalvular apparatus analysis. Methods A total of 96 consecutive patients with severe tricuspid regurgitation referred for TTVR evaluation underwent 3D-TTE, 3D-TOE, and contrast-enhanced CCT. TVA perimeter, diameters, right ventricular dimensions, and the relationship with the subvalvular apparatus were assessed using dedicated software. Procedural feasibility was adjudicated by the device manufacturer based on CT criteria. Pearson’s coefficients and Cohen’s kappa were used to assess correlation and agreement between modalities. Results Image quality was adequate in all cases. 3D-TOE showed strong correlation with CCT for TVA perimeter (r = 0.84), maximum diameter (r = 0.81), and RV diameter (r = 0.81). 3D-TTE showed moderate correlation for TVA perimeter (r = 0.78), maximum diameter (r = 0.74), and RV diameter (r = 0.51), figure 1. TTVR was deemed unfeasible in 34% of cases based on CCT. Agreement with CT-based eligibility was higher for 3D-TOE (κ = 0.78, P < 0.001) than for 3D-TTE (κ = 0.64, P < 0.001). Automated 3D-TOE analysis showed excellent discriminative performance (AUC = 0.92); the optimal cutpoint of 160 mm provided 90% sensitivity and 82% specificity (AUC at cut-point = 0.86). The echocardiographic assessment of TV apparatus compared to CCT analysis is showed in figure 2. Conclusions 3D transoesophageal echocardiography, implemented with AI automatic TVA assessment software, provides accurate anatomical assessment and strong agreement with CT in preprocedural screening for TTVR, outperforming 3D-TTE. It may serve as an effective alternative when CT is unavailable or contraindicated.Figure 1.Scatter plots: Echo TVA vs CT Figure 2.Automated echo analysys vs CT