Intracardiac echocardiography via the transesophageal route versus transesophageal echocardiography for guiding left atrial appendage occlusion

OBJECTIVES: This study sought to compare intracardiac echocardiography (ICE) probe via the esophageal route (TE-ICE) and transesophageal echocardiography (TEE) guidance for the LAAO procedure. BACKGROUND: Intraprocedural imaging guidance is recommended for all LAAO procedures. Currently, both femoral-ICE-guided and TEE-guided LAAO demonstrated similar outcomes. TE-ICE may serve as a potential alternative imaging modality in LAAO. This approach avoids general anesthesia and its potential complications, while maintaining a favorable learning curve, as it is highly similar to standard transesophageal echocardiography, with whose imaging operators are generally more familiar. METHODS: A pooled analysis of the FLXiEST and DIONISIO registries was conducted. For the purposes of this study, TE-ICE patients were compared to TEE patients. All TE-ICE procedures were performed using a 2D ICE catheter introduced via the transesophageal route. One-to-one propensity score matching was applied to compare the TE-ICE technique with the gold standard TEE in guiding LAAO. Technical success and procedural success were defined as the primary outcomes of the study. RESULTS: A total of 282 patients were included in the present study. After adjustment for clinical and echocardiographic characteristics, 99 matched-pair treated with LAAO using TE-ICE and TEE were compared. The technical success did not differ between TE-ICE and TEE patients (98 % vs 96 %; p = 0.6827). The procedural success, defined as technical success in the absence of in- hospital device or procedure-related clinical events, was comparable between the two groups (93 % vs 92 %; p = 0.7673). No statistically significant differences were found for all procedural complications assessed: death, stroke, TIA, pericardial effusion, device embolization, systemic arteria embolization and major bleeding. CONCLUSIONS: The present pooled analysis of the DIONISO and the FLXiEST demonstrated that LAAO procedure guidance can be performed with equivalent outcomes using either TE-ICE and TEE. Indeed, the use of TE-ICE technique could be particularly advantageous in high-volume centers to reduce the need for anesthesia, especially in fragile and elderly patients. This approach offers significant organizational benefits by potentially eliminating the requirement for an anesthesiologist in the cath lab, thereby streamlining workflow and improving resource allocation.