Impact of pre-procedural TEE on left atrial appendage closure strategy

Background Left atrial appendage closure (LAAC) is an effective option for patients with atrial fibrillation at high risk of stroke who are unsuitable for long-term anticoagulation. Preprocedural planning with transesophageal echocardiography (TEE) or cardiac CT is routinely performed to assess anatomy and rule out thrombus before LAAC, although the supporting evidence remains limited.¹ As the number of LAAC procedures increases and newer devices facilitate implantation, the value of routine preprocedural imaging in a resource-limited healthcare environment is uncertain. Methods We conducted a retrospective, single-centre study of patients evaluated for LAAC between 2023 and 2025 who underwent preprocedural transesophageal echocardiography (TEE). Patients were excluded if the procedure was cancelled for clinical reasons unrelated to TEE evaluation. The Heart Team determined the device recommendation (Watchman FLX Pro vs Amulet). The primary objective was to assess the clinical relevance of preprocedural TEE, defined as cancellation due to TEE findings, detection of thrombus, the need for additional imaging, and guidance on device selection. Secondary objectives included new intraprocedural TEE findings leading to cancellation, procedural success, and the final device implanted. Results A total of 122 patients were included. Four (3.3%) procedures were cancelled due to TEE findings. LAA thrombus was detected in three patients (2.5%), and additional imaging with CT or repeat TEE was recommended for 17 patients (13.9%) to further assess the LAA. Of the patients who underwent additional imaging, only one had the procedure cancelled. LAAC was deemed feasible in 118 patients (96.7%), and an Amulet device was recommended for only four patients (3.3%). Among patients with thrombus, two had a previous history of persistent thrombus despite anticoagulation therapy, and one had discontinued anticoagulation due to recurrent intracranial bleeding. The procedural success rate was 94.1%, with failures occurring due to technical challenges rather than TEE findings. Of the eight Amulet implants (7.2%), five were initially considered suitable for a Watchman device, while one patient planned for an Amulet received a Watchman device. Among the 64 patients with a device size recommendation, 37 (57.8%) received a size consistent with preprocedural planning, highlighting discrepancies between preprocedural planning and final device selection. Conclusion In LAAC programs where periprocedural TEE guidance is standard, systematic preprocedural TEE appears to provide limited additional value and may lead to unnecessary testing. A more appropriate approach may be to reserve preprocedural imaging for selected patients who are off anticoagulation or at very high thromboembolic risk. However, larger prospective studies are needed.