Intracardiac echocardiography versus transesophageal echocardiography for left atrial appendage occlusion: A systematic review and meta-analysis_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

GUO Qiong ¹ , ZHAO Qingwen ² , GU Xianlin ² , JIANG Guiyu ² , FENG Kun ³ , LONG Youlin ^1,3 , LIN Yifei ^1,4 ,  HUANG Jin ^1,3 ,  DU Liang ^1,3,5

1. Medical Device Regulatory Research and Evaluation Center, West China Hospital, Sichuan University, Chengdu, 610041, P. R. China;
2. West China School of Public Health, Sichuan University, Chengdu, 610044, P. R. China;
3. Chinese Evidence-Based Medicine Center, West China Hospital, Sichuan University, Chengdu, 610041, P. R. China;
4. Precision Medicine Center, West China Hospital, Sichuan University, Chengdu, 610041, P. R. China;
5. West China Periodical Press, West China Hospital, Sichuan University, Chengdu, 610041, P. R. China;

Corresponding author：

HUANG Jin, Email: michael_huangjin@163.com; DU Liang, Email: duliang0606@vip.sina.com

Keywords：

Intracardiac echocardiography; transesophageal echocardiography; left atrial appendage closure; meta-analysis; systematic review

DOI：

10.7507/1007-4848.202208045

Video：

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Objective To systematically evaluate the safety, efficacy, and economics of intracardiac echocardiography (ICE) versus transesophageal echocardiography (TEE) in left atrial appendage occlusion (LAAO). Methods PubMed, EMbase, The Cochrane Library, CBM, CNKI, VIP and WanFang Database were systematically searched to collect relevant studies on comparing ICE and TEE-guided LAAO from inception to June 15th, 2022. Two reviewers independently screened the literatures, extracted the data, and assessed the risk of bias of the included studies. Meta-analyses were performed using RevMan 5.3 and R 4.0.3. Retrospective cohort studies were excluded for sensitivity analysis. Subgroup analyses were performed based on the types of occluder and ICE catheter. Results A total of 14 studies with 6 599 patients were included. Meta-analyses showed no statistical differences in technical success rate, overall complications, device embolization, peri-device leakage, device-related thrombus, stroke, vascular complications, bleeding, operation time, fluoroscopy time, or contrast agent volume between the ICE and TEE-guided LAAO. The total in-room time (MD=–33.47 min, 95%CI –41.20 to –25.73, P<0.00001) and radiation dosage (MD=–170.20 mGy, 95%CI –309.79 to –30.62, P=0.02) were lower in the ICE group than those in the TEE group, whereas the incidence of pericardial effusion/tamponade was higher than the TEE group (RR=1.57, 95%CI 1.01 to 2.45, P=0.048). Except for pericardial effusion/tamponade, subgroup analyses and sensitivity analysis showed similar results. The analysis based on the cost data from the United States showed comparable or even lower total costs for ICE versus TEE, but comparative domestic cost studies were lacking. Conclusion Current evidence suggests that ICE-guided LAAO can reduce radiation dosage and total in-room time, and there is no statistical difference in the overall complication rate between the two groups. Owing to the limitations of sample size and quality of the included studies, the conclusion still needs to be verified by large sample size and high-quality randomized controlled trials.

Citation： GUO Qiong, ZHAO Qingwen, GU Xianlin, JIANG Guiyu, FENG Kun, LONG Youlin, LIN Yifei, HUANG Jin, DU Liang. Intracardiac echocardiography versus transesophageal echocardiography for left atrial appendage occlusion: A systematic review and meta-analysis. Chinese Journal of Clinical Thoracic and Cardiovascular Surgery, 2022, 29(11): 1492-1502. doi: 10.7507/1007-4848.202208045 Copy

1.	Lippi G, Sanchis-Gomar F, Cervellin G. Global epidemiology of atrial fibrillation: An increasing epidemic and public health challenge. Int J Stroke, 2021, 16(2): 217-221.
2.	Richardson AC, Omar M, Velarde G, et al. Right atrial appendage thrombus in atrial fibrillation: A case report and review of the literature. J Investig Med High Impact Case Rep, 2021, 9: 23247096211010048.
3.	许明雷. 心脏瓣膜手术同期行直视下改良双极射频消融术治疗房颤的临床研究. 山东大学, 2018.
4.	Kim DY, Shin SY, Kim JS, et al. Feasibility of intracardiac echocardiography imaging from the left superior pulmonary vein for left atrial appendage occlusion. Int J Cardiovasc Imaging, 2018, 34(10): 1571-1579.
5.	Turagam MK, Velagapudi P, Kar S, et al. Cardiovascular therapies targeting left atrial appendage. J Am Coll Cardiol, 2018, 72(4): 448-463.
6.	Jhand A, Thandra A, Gwon Y, et al. Intracardiac echocardiography versus transesophageal echocardiography for left atrial appendage closure: An updated meta-analysis and systematic review. Am J Cardiovasc Dis, 2020, 10(5): 538-547.
7.	Alkhouli M, Chaker Z, Alqahtani F, et al. Outcomes of routine intracardiac echocardiography to guide left atrial appendage occlusion. JACC Clin Electrophysiol, 2020, 6(4): 393-400.
8.	Akella K, Murtaza G, Turagam M, et al. Evaluating the role of transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE) in left atrial appendage occlusion: A meta-analysis. J Interv Card Electrophysiol, 2021, 60(1): 41-48.
9.	Whitlock RP, Belley-Cote EP, Paparella D, et al. Left atrial appendage occlusion during cardiac surgery to prevent stroke. N Engl J Med, 2021, 384(22): 2081-2091.
10.	Patti G. Intracardiac versus transesophageal echocardiography for assisting percutaneous left atrial appendage occlusion?: "Veni, vidi, vICE"! JACC Cardiovasc Interv, 2019, 12(11): 1040-1043.
11.	Berti S, Pastormerlo LE, Santoro G, et al. Intracardiac versus transesophageal echocardiographic guidance for left atrial appendage occlusion: The LAAO Italian multicenter Registry. JACC Cardiovasc Interv, 2018, 11(11): 1086-92.
12.	Liang G, Xu B, Wang S, et al. Imaging with intracardiac echocardiography compared to transesophageal echocardiography during left atrial appendage occlusion. Rev Cardiovasc Med, 2020, 21(1): 93-101.
13.	Velagapudi P, Turagam MK, Kolte D, et al. Intracardiac vs transesophageal echocardiography for percutaneous left atrial appendage occlusion: A meta-analysis. J Cardiovasc Electrophysiol, 2019, 30(4): 461-467.
14.	李亚会, 黄从新. 左心耳封堵术常见并发症及其防治. 心血管病学进展, 2021, 42(5): 4.
15.	Wan X, Wang W, Liu J, et al. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol, 2014, 14: 135.
16.	姚明宏, 李玲, 任燕, 等. 罕见事件不同Meta分析方法的统计性能评价. 中国循证医学杂志, 2021, 21(3): 367-372.
17.	翁鸿, 李胜, 曾宪涛, 等. 试验序贯分析软件在Meta分析中的应用. 中国循证医学杂志, 2016, 16(5): 604-611.
18.	Thorlund K, Engstrøm J, Wetterslev J, et al. User manual for trial sequential analysis (TSA). URL: https://ctu.dk/tsa/.
19.	Frangieh AH, Alibegovic J, Templin C, et al. Intracardiac versus transesophageal echocardiography for left atrial appendage occlusion with watchman. Catheter Cardiovasc Interv, 2017, 90(2): 331-338.
20.	Korsholm K, Jensen JM, Nielsen-Kudsk JE. intracardiac echocardiography from the left atrium for procedural guidance of transcatheter left atrial appendage occlusion. JACC Cardiovasc Interv, 2017, 10(21): 2198-2206.
21.	Reis L, Paiva L, Costa M, et al. Registry of left atrial appendage closure and initial experience with intracardiac echocardiography. Rev Port Cardiol (Engl Ed), 2018, 37(9): 763-772.
22.	Nielsen-Kudsk JE, Berti S, De Backer O, et al. Use of intracardiac compared with transesophageal echocardiography for left atrial appendage occlusion in the Amulet Observational Study. JACC Cardiovasc Interv, 2019, 12(11): 1030-1039.
23.	Streb W, Mitręga K, Podolecki T, et al. Comparison of transesophageal and intracardiac echocardiography in guiding percutaneous left atrial appendage closure with an Amplatzer Amulet device. Postepy Kardiol Interwencyjnej, 2019, 15(4): 446-454.
24.	Hemam ME, Kuroki K, Schurmann PA, et al. Left atrial appendage closure with the Watchman device using intracardiac vs transesophageal echocardiography: Procedural and cost considerations. Heart Rhythm, 2019, 16(3): 334-342.
25.	杜先锋, 冷冰, 卓伟东, 等. 心腔内超声心动图指导心房颤动一站式治疗初探. 中华心律失常学杂志, 2021, 25(6): 484-490.
26.	Gianni C, Horton RP, Della Rocca DG, et al. Intracardiac echocardiography- versus transesophageal echocardiography-guided left atrial appendage occlusion with Watchman FLX. J Cardiovasc Electrophysiol, 2021, 32(10): 2781-2784.
27.	Pommier T, Guenancia C, Richard C, et al. Safety and efficacy of left atrial appendage occlusion with the ACP or Watchman device guided by intracardiac echocardiography from the left atrium. Clin Cardiol, 2021, 44(10): 1402-1408.
28.	Morcos R, Megaly M, Saad M, et al. In-hospital outcomes of transesophageal versus intracardiac echocardiography guided left atrial appendage closure. Catheter Cardiovasc Interv, 2022, 99(5): 1572-1581.
29.	Su F, Gao C, Liu J, et al. Periprocedural outcomes associated with use of a left atrial appendage occlusion device in China. JAMA Netw Open, 2022, 5(5): e2214594.
30.	Chu H, Du X, Shen C, et al. Left atrial appendage closure with zero fluoroscopic exposure via intracardiac echocardiographic guidance. J Formos Med Assoc, 2020, 119(11): 1586-1592.
31.	Freitas-Ferraz AB, Bernier M, Vaillancourt R, et al. Safety of transesophageal echocardiography to guide structural cardiac interventions. J Am Coll Cardiol, 2020, 75(25): 3164-3173.
32.	Ribeiro JM, Teixeira R, Puga L, et al. Comparison of intracardiac and transoesophageal echocardiography for guidance of percutaneous left atrial appendage occlusion: A meta-analysis. Echocardiography, 2019, 36(7): 1330-1337.

1. Lippi G, Sanchis-Gomar F, Cervellin G. Global epidemiology of atrial fibrillation: An increasing epidemic and public health challenge. Int J Stroke, 2021, 16(2): 217-221.
2. Richardson AC, Omar M, Velarde G, et al. Right atrial appendage thrombus in atrial fibrillation: A case report and review of the literature. J Investig Med High Impact Case Rep, 2021, 9: 23247096211010048.
3. 许明雷. 心脏瓣膜手术同期行直视下改良双极射频消融术治疗房颤的临床研究. 山东大学, 2018.
4. Kim DY, Shin SY, Kim JS, et al. Feasibility of intracardiac echocardiography imaging from the left superior pulmonary vein for left atrial appendage occlusion. Int J Cardiovasc Imaging, 2018, 34(10): 1571-1579.
5. Turagam MK, Velagapudi P, Kar S, et al. Cardiovascular therapies targeting left atrial appendage. J Am Coll Cardiol, 2018, 72(4): 448-463.
6. Jhand A, Thandra A, Gwon Y, et al. Intracardiac echocardiography versus transesophageal echocardiography for left atrial appendage closure: An updated meta-analysis and systematic review. Am J Cardiovasc Dis, 2020, 10(5): 538-547.
7. Alkhouli M, Chaker Z, Alqahtani F, et al. Outcomes of routine intracardiac echocardiography to guide left atrial appendage occlusion. JACC Clin Electrophysiol, 2020, 6(4): 393-400.
8. Akella K, Murtaza G, Turagam M, et al. Evaluating the role of transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE) in left atrial appendage occlusion: A meta-analysis. J Interv Card Electrophysiol, 2021, 60(1): 41-48.
9. Whitlock RP, Belley-Cote EP, Paparella D, et al. Left atrial appendage occlusion during cardiac surgery to prevent stroke. N Engl J Med, 2021, 384(22): 2081-2091.
10. Patti G. Intracardiac versus transesophageal echocardiography for assisting percutaneous left atrial appendage occlusion?: "Veni, vidi, vICE"! JACC Cardiovasc Interv, 2019, 12(11): 1040-1043.
11. Berti S, Pastormerlo LE, Santoro G, et al. Intracardiac versus transesophageal echocardiographic guidance for left atrial appendage occlusion: The LAAO Italian multicenter Registry. JACC Cardiovasc Interv, 2018, 11(11): 1086-92.
12. Liang G, Xu B, Wang S, et al. Imaging with intracardiac echocardiography compared to transesophageal echocardiography during left atrial appendage occlusion. Rev Cardiovasc Med, 2020, 21(1): 93-101.
13. Velagapudi P, Turagam MK, Kolte D, et al. Intracardiac vs transesophageal echocardiography for percutaneous left atrial appendage occlusion: A meta-analysis. J Cardiovasc Electrophysiol, 2019, 30(4): 461-467.
14. 李亚会, 黄从新. 左心耳封堵术常见并发症及其防治. 心血管病学进展, 2021, 42(5): 4.
15. Wan X, Wang W, Liu J, et al. Estimating the sample mean and standard deviation from the sample size, median, range and/or interquartile range. BMC Med Res Methodol, 2014, 14: 135.
16. 姚明宏, 李玲, 任燕, 等. 罕见事件不同Meta分析方法的统计性能评价. 中国循证医学杂志, 2021, 21(3): 367-372.
17. 翁鸿, 李胜, 曾宪涛, 等. 试验序贯分析软件在Meta分析中的应用. 中国循证医学杂志, 2016, 16(5): 604-611.
18. Thorlund K, Engstrøm J, Wetterslev J, et al. User manual for trial sequential analysis (TSA). URL: https://ctu.dk/tsa/.
19. Frangieh AH, Alibegovic J, Templin C, et al. Intracardiac versus transesophageal echocardiography for left atrial appendage occlusion with watchman. Catheter Cardiovasc Interv, 2017, 90(2): 331-338.
20. Korsholm K, Jensen JM, Nielsen-Kudsk JE. intracardiac echocardiography from the left atrium for procedural guidance of transcatheter left atrial appendage occlusion. JACC Cardiovasc Interv, 2017, 10(21): 2198-2206.
21. Reis L, Paiva L, Costa M, et al. Registry of left atrial appendage closure and initial experience with intracardiac echocardiography. Rev Port Cardiol (Engl Ed), 2018, 37(9): 763-772.
22. Nielsen-Kudsk JE, Berti S, De Backer O, et al. Use of intracardiac compared with transesophageal echocardiography for left atrial appendage occlusion in the Amulet Observational Study. JACC Cardiovasc Interv, 2019, 12(11): 1030-1039.
23. Streb W, Mitręga K, Podolecki T, et al. Comparison of transesophageal and intracardiac echocardiography in guiding percutaneous left atrial appendage closure with an Amplatzer Amulet device. Postepy Kardiol Interwencyjnej, 2019, 15(4): 446-454.
24. Hemam ME, Kuroki K, Schurmann PA, et al. Left atrial appendage closure with the Watchman device using intracardiac vs transesophageal echocardiography: Procedural and cost considerations. Heart Rhythm, 2019, 16(3): 334-342.
25. 杜先锋, 冷冰, 卓伟东, 等. 心腔内超声心动图指导心房颤动一站式治疗初探. 中华心律失常学杂志, 2021, 25(6): 484-490.
26. Gianni C, Horton RP, Della Rocca DG, et al. Intracardiac echocardiography- versus transesophageal echocardiography-guided left atrial appendage occlusion with Watchman FLX. J Cardiovasc Electrophysiol, 2021, 32(10): 2781-2784.
27. Pommier T, Guenancia C, Richard C, et al. Safety and efficacy of left atrial appendage occlusion with the ACP or Watchman device guided by intracardiac echocardiography from the left atrium. Clin Cardiol, 2021, 44(10): 1402-1408.
28. Morcos R, Megaly M, Saad M, et al. In-hospital outcomes of transesophageal versus intracardiac echocardiography guided left atrial appendage closure. Catheter Cardiovasc Interv, 2022, 99(5): 1572-1581.
29. Su F, Gao C, Liu J, et al. Periprocedural outcomes associated with use of a left atrial appendage occlusion device in China. JAMA Netw Open, 2022, 5(5): e2214594.
30. Chu H, Du X, Shen C, et al. Left atrial appendage closure with zero fluoroscopic exposure via intracardiac echocardiographic guidance. J Formos Med Assoc, 2020, 119(11): 1586-1592.
31. Freitas-Ferraz AB, Bernier M, Vaillancourt R, et al. Safety of transesophageal echocardiography to guide structural cardiac interventions. J Am Coll Cardiol, 2020, 75(25): 3164-3173.
32. Ribeiro JM, Teixeira R, Puga L, et al. Comparison of intracardiac and transoesophageal echocardiography for guidance of percutaneous left atrial appendage occlusion: A meta-analysis. Echocardiography, 2019, 36(7): 1330-1337.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Intracardiac echocardiography versus transesophageal echocardiography for left atrial appendage occlusion: A systematic review and meta-analysis

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