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Updated: Jul 13, 2025
The WATCHMAN Left Atrial Appendage Closure Device for Atrial Fibrillation
Published on: February 28, 2012
Intracardiac vs Transesophageal Echocardiography for Left Atrial Appendage Occlusion With Watchman FLX in the U.S
Enrico G Ferro1, Mohamad Alkhouli2, Devi G Nair3
1Richard A. and Susan F. Smith Center for Outcomes Research, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA; Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.
Insights
Intracardiac echocardiography (ICE) and transesophageal echocardiography (TEE) show similar success for left atrial appendage occlusion (LAAO). However, ICE use was linked to a higher rate of pericardial effusion requiring intervention.
Area of Science:
- Cardiovascular Interventions
- Medical Imaging
- Electrophysiology
Background:
- Intraprocedural imaging is crucial for device delivery in left atrial appendage occlusion (LAAO).
- Transesophageal echocardiography (TEE) has been the standard, but intracardiac echocardiography (ICE) is an emerging alternative.
Purpose of the Study:
- To compare outcomes of Watchman FLX implantation guided by ICE versus TEE.
- To evaluate the safety and efficacy of ICE in LAAO procedures within a large nationwide registry.
Main Methods:
- Analysis of the SURPASS registry data from August 2020 to September 2021.
- Comparison of baseline characteristics and procedural outcomes between ICE- and TEE-guided LAAO using propensity weighting.
- Assessment of device implantation success, complete seal rates, and adverse events at 45 days.
Main Results:
- 39,759 LAAO procedures were analyzed; 5.7% used ICE and 80.0% used TEE.
- Successful implantation (98.3% vs 97.6%) and 45-day complete seal rates (83% vs 82%) were similar between ICE and TEE groups.
- ICE was associated with less general anesthesia use but a significantly higher rate of pericardial effusion requiring intervention (1.0% vs 0.5%).
Conclusions:
- ICE and TEE both enable high rates of successful LAAO.
- ICE is associated with a higher incidence of pericardial effusion requiring intervention, though this may decrease with operator experience.
- Further research is needed to optimize ICE utilization and mitigate associated risks in LAAO.
Background:
Intraprocedural imaging is critical for device delivery in transcatheter left atrial appendage occlusion (LAAO). Although pivotal trials of LAAO devices were conducted using transesophageal echocardiography (TEE), intracardiac echocardiography (ICE) is an emerging imaging modality.
Objectives:
This study compared outcomes after ICE- and TEE-guided Watchman FLX implantation in the SURPASS (SURveillance Post Approval AnalySiS Plan) nationwide LAAO registry.
Methods:
Baseline characteristics were compared using chi-square and t-tests. Outcomes were reported in unadjusted and adjusted comparisons via propensity weighting.
Results:
Between August 2020 and September 2021, LAAO was attempted in 39,759 patients at 698 sites, including 2,272 cases (5.7%) with ICE and 31,835 (80.0%) with TEE. ICE and TEE patients had similar baseline characteristics and mean procedural times (ICE 82 minutes vs TEE 78 minutes). ICE patients were less likely to receive general anesthesia (54% vs 98%, P < 0.01). Successful device implantation (98.3% vs 97.6%) and complete seal rates at 45 days were similar (n = 25,280; 83% vs 82%). Most adverse event rates were similar; unadjusted mortality rates at 45 days were 1.1% for ICE vs 0.8% for TEE (P = 0.14), and 1.0% vs 0.7% (P = 0.27) in adjusted analyses. Even after adjustment, pericardial effusion rates requiring intervention were significantly higher with ICE at 45 days (1.0% vs 0.5%; P = 0.02). This rate decreased as operators performed more ICE-guided procedures, although 82% of operators had performed <10 ICE-guided procedures overall.
Conclusions:
In the largest comparison to date, ICE use was infrequent. ICE and TEE both achieved high rates of complete LAAO. ICE was associated with significantly higher rates of pericardial effusion requiring intervention.
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