Outcomes with intracardiac versus transesophageal echocardiography-guided left atrial appendage occlusion.

Background
Left atrial appendage occlusion (LAAO) has been validated as a safe and effective alternative to anticoagulation in patients with atrial fibrillation and high bleeding risk. Transesophageal echocardiography (TEE) is the gold standard imaging modality during LAAO. Whether intracardiac echocardiography (ICE) can be used as an alternative to TEE is unknown.

Methods
We performed a systematic review and meta-analysis according to the PRISMA guidelines and included studies from inception until December 2018 comparing outcomes with ICE- vs. TEE-guided LAAO. The primary outcome was procedural success, defined as technical success without major procedure-related complications. Secondary outcomes included pericardial tamponade, stroke, major bleeding, and device embolization. Devices used were the Watchman device, ACP device, and ACP II device. Random effects DerSimonian-Laird odds ratios (OR) for outcomes were calculated.

Results
Three studies with 896 patients (ICE arm n= 328, TEE arm n= 568) were included. Procedural success rate was 97% vs. 94.3% in the ICE and TEE arms, respectively (p=0.09). The use of ICE was associated with similar risk of device embolization (OR: 0.98, 95% CI [0.12, 8.00], p=0.98, I²=0%), stroke (OR: 0.37, 95% CI [0.04, 3.32], p=0.37, I²=0%), major bleeding (OR: 0.37, 95% CI [0.12, 1.16], p=0.09, I²=0%) and cardiac tamponade (OR: 1.2, 95% CI [0.29, 4.95], p=0.81, I²=12%) compared with TEE (Figure 1).

Conclusions
Intracardiac echocardiography is a feasible and safe alternative to TEE in LAAO procedures. Large randomized trials are needed to confirm these results.