Intracardiac echocardiography utilization in early commercial transcatheter tricuspid valve replacement

Abstract Background and Aims Transcatheter tricuspid valve replacement (TTVR) is a novel treatment for patients with severe tricuspid regurgitation (TR). Procedural success hinges on intraprocedural imaging quality. Three-dimensional intracardiac echocardiography (3D-ICE) is an important adjunctive imaging modality in this setting; however, data on optimal use strategies remain limited. Methods and results Retrospective review of 100 patients undergoing TTVR at a single centre between February 2024 and April 2025 was conducted. 3D-ICE was employed selectively as adjunctive imaging when transoesophageal echocardiography (TEE) was suboptimal. Baseline characteristics and procedural outcomes were analysed. 3D-ICE was used in 29 patients. Baseline characteristics were similar between groups, although patients requiring ICE had higher prevalence of cardiovascular implanted electronic devices (CIED) (52% vs. 24%, P < .05). Procedural duration was longer in 3D-ICE patients, (141 [IQR 123, 180] min) compared with TEE-alone, (115 [100, 138] min, P < .05), although this improved over time. Post-procedurally, patients requiring adjunctive 3D-ICE had more residual TR (>mild in 14% vs. 3%, P < .05). There was no difference in 30-day mortality (3.4% ICE vs. 5.6%, P = .65) or Kansas City Cardiomyopathy-Questionnaire scores at follow-up (65% ICE vs. 51%, P = .24). Conclusions This is the first large-scale report of 3D-ICE use during TTVR with EVOQUE (Edwards Lifesciences, Irvine, USA). 3D-ICE was employed when TEE was suboptimal, often in patients with CIEDs. Its use correlated with longer procedures and more residual TR, likely reflecting higher case complexity, though clinical outcomes were equal. Procedural efficiency improved over time, with no cases aborted due to imaging. Primary 3D-ICE approach may have similar procedural time without affecting safety, supporting further evaluation of up-front ICE use and focused training.