Reviews in Cardiovascular Medicine  2020, Vol. 21 Issue (1): 93-101     DOI: 10.31083/j.rcm.2020.01.569 Imaging with intracardiac echocardiography compared to transesophageal echocardiography during left atrial appendage occlusion Guicheng Liang1, Beizhu Xu1, Shirong Wang1, Chengxuan Li1, Guoqiang Zhong1, *() 1 Department of Cardiology, First Affiliated Hospital of Guangxi Medical University, No. 6 Shuangyong Road, Nanning, 530021, Guangxi, P. R. China. Abstract:

We performed a meta-analysis comparing the procedural and outcomes data and related to left atrial appendage occlusion guided by intracardiac echocardiography (ICE) and transesophageal echocardiography (TEE) in nonvalvular atrial fibrillation patients. Technical success with ICE was significantly similar to that of TEE (odds ratio [OR] 1.38, 95% CI [0.62, 3.09], I2 = 0%, P = 0.43). The peri-procedural complications showed no significant difference between the two groups (OR 0.84, 95% CI [0.57, 1.23], I2 = 0%, P = 0.37). Mortality was similar in procedures using ICE vs TEE (OR 0.89, 95% CI [0.51, 1.57], I2 = 0%, P = 0.69). Landing zones, procedural time and fluoroscopic times between ICE and TEE showed no significant differences (MD 1.96, 95% CI [-0.01, 3.94], I2 = 90%, P = 0.05; MD -1.64, 95% CI [-13.45, 10.17], I2 =95%, P = 0.79; and MD 0.49, 95% CI [-2.18, 3.16], I2= 87%, P = 0.72, respectively). Imaging with ICE or TEE is associated with similar outcomes in left atrial appendage occlusion procedures.

Submitted:  29 September 2019      Accepted:  29 December 2019      Published:  30 March 2020      *Corresponding Author(s):  Guoqiang Zhong     E-mail:  Zhgq17@163.com Service E-mail this article Add to citation manager E-mail Alert RSS Articles by authors Guicheng Liang    Beizhu Xu    Shirong Wang    Chengxuan Li    Guoqiang Zhong   

Figure 1.  Flowchart of the processing of the included studies

Table 1.  Baseline information of the included studies

StudyYearCountryICETEEFollow-upPrimary endpointsMen, N (%)Age (years)Men, N (%)Age(years)Aguirre2018Chile13 (59.1)74 ± 9.313 (59.1)74 ± 9.330 daysdeath, pericardial effusion, MI, stroke, renal failure, length of hospital stayBerti2014Italy69 (57)77 ± 7.669 (57)77 ± 7.6within 24 hpericardial effusion, device embolization, stroke, bleeding, hematoma, othersBerti2018Italy123 (66)76 ± 8271 (65)74 ± 76, 12 monthsdeath, tamponade, stroke, TIA, systemic embolism, major bleeding, device embolizationClemente2015Italy78 ± 678 ± 65.2 ± 6 monthsresidual leaksFrangieh2017Switzerland26 (81)76 ± 8.925 (57)81 ± 7.4in hospitaldeath, tamponade, pericardial effusion, device embolization, stroke, peridevice leak, bleeding, renal failureFrikha2016Canada74.4 ± 7.674.4 ± 7.63 monthstamponade, MI, device embolization, stroke, hematomaHemam2019USA33 (62.3)77 ± 1031 (60.8)76 ± 745-120 ddeath, tamponade, device embolization, stroke, hematoma, peridevice flowHo, I2007USA8 (80)67.1 ± 8.48 (80)67.1 ± 8.412 monthsstrokes, transient ischemic attacksIwasawa2016USAnnnnndeath, tamponade, bleeding, hematomasKim2018Korea24 (58.5)71.4 ± 9.351 (49.5)72.3 ± 9.22 weeks, 3 monthsdeath, tamponade, pericardial effusion, stroke, MI, device embolization, air-embolization, thrombusKorsholm2017Denmark68 (62)73 ± 7.879 (74)73 ± 9.78 weeksdeath, pericardial effusion, device embolization, stroke, bleeding, hematoma, pseudoaneurysmMasson2015Canada25 (67.6)74.7 ± 8.225 (67.6)74.7 ± 8.23 monthstamponade, MI, bleedingMatsuo2016Czech11 (40.7)77.0 ± 8.511 (40.7)77.0 ± 8.545 ddeath, pericardial effusion, stroke, hematoma, othersNaim C2015Canada75 ± 875 ± 83 monthstamponade, device embolization, stroke, hematomaReis2018Portugal53 (64.6)74 ± 853 (64.6)74 ± 86-12 monthsdeath, tamponade, pericardial effusion, stroke, hematoma, bleeding

Table 2.  Periprocedural complications

StudyYearICETEEn = 823n = 1236Aguirre2018renal failure (1), Length of hospital (1)renal failure (1), Length of hospital (1)Berti2014Serious pericardial effusion (3), Procedure-related ischemic stroke (1), Femoral hematoma (2)Serious pericardial effusion (3), Procedure-related ischemic stroke (1), Femoral hematoma (2)Berti2018TIA (1), Device embolization (1), Pericardial tamponade (3), Major bleeding (3)Ischemic stroke (1), TIA (1), Device embolization (1), Pericardial tamponade (8), Major bleeding (16)Frangieh2017pericardial effusion (1)esophageal erosion with bleeding (1), non-LAAO related death (1)Frikha2016Tamponade (1), silent MI (1), hematoma (3)Tamponade (1), silent MI (1), hematoma (3)Iwasawa2016groin hematoma (2)cardiac tamponade (1), retro-peritoneal bleed (1), groin hematoma (2)Kim2018Pericardial effusion (1)Cardiac tamponade (1), Pericardial effusion (2), Device embolization (3), Vascular complications (1)Korsholm2017Pericardial effusion with tamponade (2), Access-site hematoma (3), Pseudoaneurysm (1)Device embolization n (1), Ischemic stroke (1), Hemorrhagic stroke (1), Major extracranial bleeding (2), Access-site hematoma (1)Masson2015Tamponade (1), Silent myocardial infarction (1), bleed (1)pulmonary embolism (1), heart failure (1), bleed (1)Matsuo2016pericardial effusion (1), hematoma (3), transient dizziness (1)Hematoma (3)
others(2)Naim C2015Tamponade (2), hematoma (2)residual leak (2), bleeding (2)Reis2018pericardial effusion (2), hematoma (1)residual leak (5), bleeding (4)Total5.6%6.5%

Table 3.  Procedural endpoints

StudyYearLanding zone (mm)Procedural time (min)Fluoroscopic time (min)Contrast usage (ml)ICETEEICETEEICETEEICETEEBerti2018108 ± 3392 ± 3425 ± 1220 ± 11Clemente201521 ± 2.816.9 ± 3.7Frangieh201748 ± 14.834.5 ± 12.69.8 ± 4.67.9 ± 6.7485 ± 21.790 ± 63.7Hemam201921.27 ± 3.2721.5 ± 4.6846 ± 2446 ± 304.8 ± 2.77.3 ± 4.7Ho, I200722.6 ± 3.419.5 ± 1.5Iwasawa201653 ± 3157 ± 30Kim201826.0 ± 1.525.9 ± 1.458.0 ± 4.4480.0 ± 27.417.6 ± 3.788.3 ± 10.81Korsholm201744 ± 11.955 ± 28.115 ± 5.914 ± 8.960 ± 17.770 ± 20Masson2015105 ± 3425 ± 10155 ± 69Matsuo201623.7 ± 3.820.4 ± 5.42.98 ± 0.8Naim C201591.0 ± 28.1Reis201865.8 ± 15.269.9 ± 13.630.4 ± 17.035.1 ± 16.5

Table 4.  , NOS quality assessment of the included studies

StudySelectionComparabilityOutcomeAguirre★★★★★★Berti 2014★★★★★Berti 2018★★★★★★★Clemente★★★★★Frangieh★★★★★Frikha★★★★★★Hemam★★★★★★★Ho, I★★★★★★★Iwasawa★★★Kim★★★★★★Korsholm★★★★★★★Masson★★★★★★Matsuo★★★★★★Naim C★★★★★★Reis★★★★★★★

Figure 2.  Forest plot of the technical success of ICE vs TEE.

Figure 3.  Forest plot of periprocedural complications.

Figure 4.  Funnel plot of periprocedural complications.

Figure 5.  Forest plot of the measurements of the LZ for ICE vs TEE. Random effects model.

Figure 6.  Forest plot of the procedural time for ICE vs TEE. Random effects model.

Figure 7.  Forest plot of the fluoroscopic time for ICE vs TEE. Random effects model.

Figure 8.  ICE guidance for LAAO. (A) Interatrial septal puncture (ICE probe in the right atrium); (B) visualization of the LAA and anatomy assessment (ICE probe in the left atrium); (C) device position assessment; (D) check for peri-device flow/leak with color Doppler-flow imaging. LAA: left atrial appendage; LA: left atrium; RA: right atrium; W: Watchman device.

Figure 9.  TEE guidance for LAAO. (A) Interatrial septal puncture; (B) visualization of the LAA and anatomy assessment; (C) device position assessment; (D) check for peri-device flow/leak with color Doppler-flow imaging (the red color indicates the flow toward the left atrium and not a leak since the flow is a lower velocity and no peri-device penetration detected). LAA: left atrial appendage; LA: left atrium; MV: mitral valve; RA: right atrium; W: Watchman device.

[1] Aguirre, D.,Pincetti, C.,Perez, L.,Deck, C.,Alfaro, M.,Vergara, M. J. and Maluenda, G. (2018)Single Trans-Septal Access Technique for Left Atrial Intracardiac Echocardiography to Guide Left Atrial Appendage Closure.Catheterization and Cardiovascular Interventions 91, 356-361. [2] Berti, S.,Paradossi, U.,Meucci, F.,Trianni, G.,Tzikas, A.,Rezzaghi, M.,Stolkova, M.,Palmieri, C.,Mori, F. and Santoro, G. (2014)Periprocedural Intracardiac Echocardiography for Left Atrial Appendage Closure: A Dual-Center Experience.JACC Cardiovascular Interventions 7, 1036-1044. [3] Berti, S.,Pastormerlo, L. E.,Santoro, G.,Brscic, E.,Montorfano, M.,Vignali, L.,Danna, P.,Tondo, C.,Rezzaghi, M.,D'Amico, G.,Stabile, A.,Sacca, S.,Patti, G.,Rapacciuolo, A.,Poli, A.,Golino, P.,Magnavacchi, P.,Meucci, F.,Pezzulich, B.,Stolcova, M. and Tarantini, G. (2018)Intracardiac Versus Transesophageal Echocardiographic Guidance for Left Atrial Appendage Occlusion: The Laao Italian Multicenter Registry.JACC Cardiovascular Interventions 11, 1086-1092. [4] Biermann, J.,Bode, C. and Asbach, S. (2012)Intracardiac Echocardiography During Catheter-Based Ablation of Atrial Fibrillation.Cardiology Research and Practice 2012,921746. [5] Clemente, A.,Avogliero, F.,Berti, S.,Paradossi, U.,Jamagidze, G.,Rezzaghi, M.,Della Latta, D. and Chiappino, D. (2015)Multimodality Imaging in Preoperative Assessment of Left Atrial Appendage Transcatheter Occlusion with the Amplatzer Cardiac Plug.European Heart Journal Cardiovascular Imaging 16, 1276-1287. [6] Frangieh, A. H.,Alibegovic, J.,Templin, C.,Gaemperli, O.,Obeid, S.,Manka, R.,Holy, E. W.,Maier, W.,Luscher, T. F. and Binder, R. K. (2017)Intracardiac Versus Transesophageal Echocardiography for Left Atrial Appendage Occlusion with Watchman.Catheterization and Cardiovascular Interventions 90, 331-338. [7] Frikha, Z.,El hammiri, A.,Potvin, J.,Raymond, J. M. and Masson, J. B. (2016)Periprocedural Intracardiac Echocardiography from the Left Atrium for Left Atrial Appendage Occlusion with the Amplatzer Cardiac Plug™.Journal of the American College of Cardiology 68, B252. [8] Hemam, M. E.,Kuroki, K.,Schurmann, P. A.,Dave, A. S.,Rodriguez, D. A.,Saenz, L. C.,Reddy, V. Y. and Valderrabano, M. (2019)Left Atrial Appendage Closure with the Watchman Device Using Intracardiac Vs Transesophageal Echocardiography: Procedural and Cost Considerations.Heart Rhythm 16, 334-342. [9] Hijazi, Z. M.,Shivkumar, K. and Sahn, D. J. (2009)Intracardiac Echocardiography During Interventional and Electrophysiological Cardiac Catheterization.Circulation 119, 587-596. [10] Ho, I. C.,Neuzil, P.,Mraz, T.,Beldova, Z.,Gross, D.,Formanek, P.,Taborsky, M.,Niederle, P.,Ruskin, J. N. and Reddy, V. Y. (2007)Use of Intracardiac Echocardiography to Guide Implantation of a Left Atrial Appendage Occlusion Device (Plaato).Heart Rhythm 4, 567-571. [11] Iwasawa, J.,Enomoto, Y.,Sharma, D.,Palaniswamy, C.,Baluad, S.,Choudry, S.,Langan, N.,Miller, M.,Koruth, J.,Dukkipati, S. and Reddy, V. (2016)Abstract 16647: Implantation of the Watchman Left Atrial Appendage Closure Device: A Comparison of Tee-Guidance Vs Ice-Guidance.Circulation 134, A16647. [12] Kim, D. Y.,Shin, S. Y.,Kim, J. S.,Kim, S. H.,Kim, Y. H. and Lim, H. E. (2018)Feasibility of Intracardiac Echocardiography Imaging from the Left Superior Pulmonary Vein for Left Atrial Appendage Occlusion.The International Journal of Cardiovascular Imaging 34, 1571-1579. [13] Kirchhof, P.,Benussi, S.,Kotecha, D.,Ahlsson, A.,Atar, D.,Casadei, B.,Castella, M.,Diener, H. C.,Heidbuchel, H.,Hendriks, J.,Hindricks, G.,Manolis, A. S.,Oldgren, J.,Popescu, B. A.,Schotten, U.,Van Putte, B.,Vardas, P.,Agewall, S.,Camm, J.,Esquivias, G. B.,Budts, W.,Carerj, S.,Casselman, F.,Coca, A.,De Caterina, R.,Deftereos, S.,Dobrev, D.,Ferro, J. M.,Filippatos, G.,Fitzsimons, D.,Gorenek, B.,Guenoun, M.,Hohnloser, S. H.,Kolh, P.,Lip, G. Y. H.,Manolis, A.,McMurray, J.,Ponikowski, P.,Rosenhek, R.,Ruschitzka, F.,Savelieva, I.,Sharma, S.,Suwalski, P.,Tamargo, J. L.,Taylor, C. J.,Van Gelder, I. C.,Voors, A. A.,Windecker, S.,Zamorano, J. L. and Zeppenfeld, K. (2016)2016 ESC Guidelines for the management of atrial fibrillation developed in collaboration with EACTS.European Heart Journal 37, 2893-2962. [14] Korsholm, K.,Jensen, J. M. and Nielsen-Kudsk, J. E. (2017)Intracardiac Echocardiography from the Left Atrium for Procedural Guidance of Transcatheter Left Atrial Appendage Occlusion.JACC Cardiovascular Interventions 10, 2198-2206. [15] Masson, J. B.,Kouz, R.,Riahi, M.,Nguyen Thanh, H. K.,Potvin, J.,Naim, C.,Salem, R. and Raymond, J. M. (2015)Transcatheter Left Atrial Appendage Closure Using Intracardiac Echocardiographic Guidance from the Left Atrium.The Canadian Journal of Cardiology 31, 1497.e1497-1497.e1414. [16] Matsuo, Y.,Neuzil, P.,Petru, J.,Chovanec, M.,Janotka, M.,Choudry, S.,Skoda, J.,Sediva, L.,Kurabayashi, M. and Reddy, V. Y. (2016)Left Atrial Appendage Closure under Intracardiac Echocardiographic Guidance: Feasibility and Comparison with Transesophageal Echocardiography.Journal of the American Heart Association 5, e003695. [17] Moher, D.,Liberati, A.,Tetzlaff, J. and Altman, D. G. (2009)Preferred Reporting Items for Systematic Reviews and Meta-Analyses: The Prisma Statement.PLoS Medicine 6, e1000097. [18] Moradkhan, R.,Amani, F.,Banchs, J. E.,Patel, P. and Gonzalez, M. D. (2012)Intracardiac Echocardiography Visualization of the Left Atrial Appendage from the Right Ventricular Inflow Tract. Comparison with Transesoophageal Echocardiography.Heart Rhythm 9, S112-S113. [19] Naim, C.,Potvin, J.,El hammiri, A. and Masson, J. B. (2015)Left Atrial Appendage Closure under Local Anesthesia; Initial Experience from a Single Center Prospective Registry for Laa Occlusion under Ice Guidance from the Left Atrium.Journal of the American College of Cardiology 66, B297-B298. [20] Reddy, V. Y.,Holmes, D.,Doshi, S. K.,Neuzil, P. and Kar, S. (2011)Safety of Percutaneous Left Atrial Appendage Closure Results from the Watchman Left Atrial Appendage System for Embolic Protection in Patients with Af (Protect Af) Clinical Trial and the Continued Access Registry.Circulation 123, 417-424. [21] Reis, L.,Paiva, L.,Costa, M.,Silva, J.,Teixeira, R.,Botelho, A.,Dinis, P.,Madeira, M.,Ribeiro, J.,Nascimento, J. and Gonçalves, L. (2018)Registry of Left Atrial Appendage Closure and Initial Experience with Intracardiac Echocardiography.Revista Portuguesa de Cardiologia 37, 763-772. [22] Ren, J. F.,Marchlinski, F. E.,Supple, G. E.,Hutchinson, M. D.,Garcia, F. C.,Riley, M. P.,Lin, D.,Zado, E. S.,Callans, D. J. and Ferrari, V. A. (2013)Intracardiac Echocardiographic Diagnosis of Thrombus Formation in the Left Atrial Appendage: A Complementary Role to Transesophageal Echocardiography.Echocardiogr-J Card 30, 72-80. [23] Velagapudi, P.,Turagam, M. K.,Kolte, D.,Khera, S.,Gupta, T.,Garg, J.,Abbott, J. D.,George, I.,Khalique, O.,Vahl, T.,Nazif, T.,Lakkireddy, D.,Kodali, S. and Sommer, R. (2019)Intracardiac Vs Transesophageal Echocardiography for Percutaneous Left Atrial Appendage Occlusion: A Meta-Analysis.Journal of Cardiovascular Electrophysiology 30, 461-467. [24] Wells GA,Shea B,O'Connell D,Peterson J,Welch V,Losos M,Tugwell P.The Newcastle-Ottawa Scale (NOS) for Assessing the Quality of Nonrandomised Studies in Meta-analyses.Ottawa: Ottawa Hospital Research Institute .http:// www. ohri.ca/programs/clinical_epidemiology/oxford.asp (accessed 16 Jun 2019). [25] Wunderlich, N. C.,Beigel, R.,Swaans, M. J.,Ho, S. Y. and Siegel, R. J. (2015)Percutaneous Interventions for Left Atrial Appendage Exclusion Options, Assessment, and Imaging Using 2d and 3d Echocardiography.JACC: Cardiovascular Imaging 8, 473-488. No Suggested Reading articles found! Viewed Full text


Abstract

Cited

  Shared      Discussed