Intracardiac echocardiography versus transesophageal echocardiography guidance on left atrial appendage occlusion in patients with atrial fibrillation: A systematic review and meta-analysis

Abstract

Background: Intracardiac echocardiography (ICE) is an innovative technique that has emerged as an alternative to transesophageal echocardiography (TEE) to guide the implantation of a left atrial appendage occlusion (LAAO) device in patients with nonvalvular atrial fibrillation (AF) who cannot tolerate anticoagulants. Purpose: We aim to review the clinical efficacy and safety of ICE compared to TEE to guide the implantation of LAAO devices in patients with AF. Methods: We conducted comprehensive searches across PubMed, CENTRAL, Web of Science, Scopus, and EMBASE until March 2024. Pooled data were reported using risk ratio (RR) for dichotomous outcomes and mean difference (MD) for continuous outcomes, along with a 95% confidence interval (CI). This systematic review and meta-analysis was registered with PROSPERO ID: CRD42024542537. Results: We included 19 studies involving 44,706 patients. ICE was associated with a statistically significant high procedure success rate compared to TEE (RR: 1.0055 with 95% CI [1.0006, 1.0104], p = 0.01), but there was no difference in procedure duration (MD: 3.07 with 95% CI [-4.67, 10.80], p = 0.44) between the two groups. However, compared to the ICE group, patients undergoing LAAO under TEE guidance required more than one device more often (RR: 1.39 with 95% CI [1.23, 1.57], p < 0.01). The TEE group also reported a reduced incidence of pericardial effusion compared to the ICE group (RR: 0.65 with 95% CI [0.50, 0.85], p < 0.01). Conclusion: Our meta-analysis concluded that ICE can be a viable alternative to TEE for guiding LAAO, particularly in patients unsuitable for general anesthesia. It can also reduce the need for GA and adverse effects and resources associated with it, require fewer devices, and demonstrate comparable safety and efficacy outcomes, though it may increase the risk of pericardial effusion. Further prospective trials are warranted.