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Intracardiac Echo to Guide LAA Occlusion
Study Questions:
How do procedural feasibility, procedural safety, hospital charges, and short-term efficacy compare between intracardiac echocardiography (ICE) and transesophageal echocardiography (TEE) guidance of transcatheter left atrial appendage occlusion (LAAO)?
Methods:
In a single-center, prospective, nonrandomized registry study, consecutive patients who underwent LAAO with ICE or with TEE guidance at the West Virginia University Clinic were compared for the following endpoints: 1) technical success (ability to successfully implant a device); 2) procedure-related events (pericardial effusion requiring intervention, major vascular complication, procedure-related stroke, death, or device embolization); 3) hospital charges (facility fees and physician fees); and 4) peridevice leak >5 mm, device embolization, or device thrombus at 45 days.
Results:
After excluding patients who underwent a concomitant non-LAAO intervention, 286 patients (196 TEE, 90 ICE) were enrolled. Baseline characteristics were similar. Technical success was achieved in 97.8% and 97.4% of the patients in the ICE and TEE groups, respectively (p = 0.88). No patient in the ICE group required conversion to TEE or general anesthesia. Major procedure-related events occurred in 3.3% and 4.1% of the patients in the ICE and TEE groups, respectively (p = 0.76). Procedural and fluoroscopy times were similar (35.2 ± 11.3 minutes [min] vs. 36.6 ± 15.6 min, p = 0.42; and 14.2 ± 3.6 min vs. 13.8 ± 8.9 min, p = 0.67, respectively). However, in-room time was shorter with ICE (78.7 ± 19.5 min vs. 113.6 ± 18.1 min, p < 0.001). Although hospital charges were higher with ICE ($76,366 ± $8,028 vs. $71,114 ± $10,802, p < 0.001), professional fees were higher with TEE ($6,033 ± $1,081 vs. $2,654 ± $395, p < 0.001); and global charges were similar with ICE and TEE ($79,020 ± $8,241 vs. $77,147 ± $10,941, p = 0.15). Follow-up imaging at 45 ± 15 days showed similar rates of peridevice leaks, device thrombi, and iatrogenic atrial septal defects.
Conclusions:
The authors concluded that ICE-guided LAAO is associated with similar outcomes and hospital charges compared with TEE-guided LAAO.
Perspective:
This single-center, observational study suggests that ICE-guided transcatheter LAAO procedures have similar outcomes and similar hospital charges compared to TEE-guided procedures. As a nonrandomized study, there is an inherent potential for selection bias, and there were observed differences or trends toward differences between groups in some baseline clinical characteristics. In addition, there was a difference between groups in the modality of imaging used at follow-up, with more cardiac computed tomography rather than follow-up TEE in the ICE cohort. If there might be concern for a higher rate of vascular complications in the ICE cohort, the relatively small sample size and low complication rate led to analysis only of the combined safety endpoint, without the ability to compare the rates of individual adverse events. Overall, the study supports the feasibility and safety of ICE instead of TEE for the guidance of transcatheter LAAO. As always, confirming data from multiple centers, ideally in a randomized trial, would be of interest.
Clinical Topics: Arrhythmias and Clinical EP, Congenital Heart Disease and Pediatric Cardiology, Noninvasive Imaging, Pericardial Disease, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Congenital Heart Disease, CHD and Pediatrics and Arrhythmias, CHD and Pediatrics and Imaging, Echocardiography/Ultrasound, Nuclear Imaging
Keywords: Arrhythmias, Cardiac, Atrial Appendage, Coronary Occlusion, Diagnostic Imaging, Echocardiography, Transesophageal, Echocardiography, Embolization, Therapeutic, Fluoroscopy, Heart Septal Defects, Atrial, Pericardial Effusion, Stroke, Thrombosis, Vascular Diseases
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