Intracardiac echocardiography versus transesophageal echocardiography for left atrial appendage closure: an updated meta-analysis and systematic review

Intracardiac echocardiography (ICE) has emerged as an alternative to transesophageal echocardiography (TEE) to guide implantation of percutaneous left atrial appendage closure (LAAC) devices in patients with atrial fibrillation (AF) and a high bleeding risk. We reviewed the efficacy and safety of ICE compared to TEE in LAAC in this updated meta-analysis. Medline, CINAHL, EMBASE and Scopus were systematically searched for studies comparing ICE and TEE in percutaneous LAAC. Our primary outcomes of interest were procedural success and study reported periprocedural complications. Secondary outcomes included various procedural characteristics. Risk ratios (RR), standardized mean differences (SMD) and their corresponding 95% confidence intervals (CI) were calculated. The analysis was performed using a random-effect model. Nine observational studies met our inclusion criteria with a total of 2620 patients (ICE: 679 and TEE: 1941). Mean CHA₂DS₂-Vasc (4.4 ± 0.3 for ICE vs 4.5 ± 0.3 for TEE, P = 0.60) and HAS-BLED (3.2 ± 0.4 vs 3.1 ± 0.6, P = 0.78) scores were comparable between the two groups. There was no significant difference in procedure success rate (RR: 1.01, 95% CI: 0.99-1.02, P= 0.31) and periprocedural complications (RR: 0.85, 95% CI: 0.59-1.23, P = 0.39). No significant difference was observed in procedure duration, fluoroscopy time and contrast volume used while a trend towards decreased hospital length of stay was seen with the use of ICE. Thus, our updated meta-analysis shows ICE is as effective and safe as TEE for implantation of LAAC devices.