ICE vs. TEE Guidance for LA Appendage Occlusion

Study Questions:

What is the feasibility, safety, and efficacy of intracardiac echocardiography (ICE)–guided versus transesophageal echocardiography (TEE)–guided left atrial appendage occlusion (LAAO) by the use of Amplatzer Cardiac Plug or Amulet devices?


The investigators reviewed data from 604 LAAO procedures performed in 16 Italian centers. ICE-guided LAAO was performed in 187 patients, whereas TEE was used in 417 patients. Procedural success was defined as LAAO without occurrence of pericardial tamponade, stroke, systemic embolism with end-organ damage, major bleeding, and device embolization. Stroke, transient ischemic attack, major bleeding, overall death, and cardiovascular death were analyzed. Events curves were analyzed using the Kaplan-Meier estimate. Differences in survival curves were tested with the log-rank test.


CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes mellitus, prior stroke or transient ischemic attack or thromboembolism, vascular disease, age 65-74 years, sex category) and HAS-BLED (hypertension, abnormal renal and liver function, stroke, bleeding, labile international normalized ratio, elderly, drugs or alcohol) scores were similar between the ICE and TEE groups. TEE implied lower procedural (delta 12 minutes) and fluoroscopy time (delta 5 minutes) when compared with ICE. Procedural success was similarly high (≥94%) between the TEE and ICE groups, with a complication rate of 6.5% for TEE versus 4.2% for ICE (odds ratio, 1.468; 95% confidence interval, 0.681-3.166; p = 0.327). At median follow-up of 451 days (interquartile range, 162-899 days), the rate of cerebral ischemic events was similar between TEE-guided and ICE-guided procedures.


The authors concluded that ICE-guided LAAO by means of Amplatzer devices may represent a second alternative imaging modality.


This study, analyzing the comparative value of ICE versus TEE in guiding LAAO, reports that the ICE-guided procedure appears to be feasible and safe at early and mid-term follow-up when compared with patients undergoing TEE-guided procedures. However, currently available data suggest that TEE is the gold standard for LAAO procedure guidance. ICE-guided LAAO by means of Amplatzer devices may represent a second alternative imaging modality after an appropriate learning curve, while keeping in mind that preprocedural computed tomography imaging is mandatory. Furthermore, these results on ICE-guided LAAO procedures need to be confirmed on a larger cohort of patients with adequate long-term imaging follow-up.

Clinical Topics: Arrhythmias and Clinical EP, Noninvasive Imaging, Prevention, Implantable Devices, SCD/Ventricular Arrhythmias, Atrial Fibrillation/Supraventricular Arrhythmias, Computed Tomography, Echocardiography/Ultrasound, Nuclear Imaging

Keywords: Arrhythmias, Cardiac, Atrial Appendage, Coronary Occlusion, Diagnostic Imaging, Echocardiography, Transesophageal, Echocardiography, Embolism, Fluoroscopy, Hemorrhage, Ischemic Attack, Transient, Secondary Prevention, Stroke, Tomography, X-Ray Computed

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