Clinical Protocol for Selecting Intracardiac or Transesophageal Echocardiography-Guided Left Atrial Appendage Occlusion

• Published in: The American journal of cardiology 2024-07, Vol.222, p.87-94
• Main Authors: Stout, Kara, Craig, Calvin, Rivington, Jaclyn, Lyden, Elizabeth, Payne, Jason J., Goldsweig, Andrew M.
• Format: Article
• Language: English
• Subjects: Aged; Aged, 80 and over; Anesthesia; Anticoagulants; Appendages; Aspirin; Atrial Appendage - diagnostic imaging; Atrial Appendage - surgery; Atrial Fibrillation - surgery; Blood clots; Cardiac arrhythmia; Cardiac Catheterization - methods; Clinical Protocols; Echocardiography; Echocardiography - methods; Echocardiography, Transesophageal - methods; Female; General anesthesia; Humans; intracardiac echocardiography; LAAO; left atrial appendage occlusion; Male; Occlusion; Patient Selection; Patients; Renal function; Retrospective Studies; Stroke - epidemiology; Stroke - etiology; Stroke - prevention & control; Success; Surgery, Computer-Assisted - methods; Thrombosis; transesophageal echocardiography; Ultrasonography, Interventional - methods
• ISSN: 0002-9149; 1879-1913; 1879-1913
• DOI: 10.1016/j.amjcard.2024.04.023

•This protocol guides safe, efficacious case selection for intracardiac echocardiography (ICE)-guided left atrial appendage occlusion (LAAO).•ICE-guided LAAO is superior to transesophageal echocardiography (TEE)-guided with fewer procedural complications.•ICE-guided LAAO procedures are shorter and avoid general anesthesia compared with TEE.•One-year follow-up shows similar outcomes for ICE and TEE-guided LAAO. Intracardiac echocardiography (ICE) has emerged as an alternative to transesophageal echo (TEE) to guide left atrial appendage occlusion (LAAO). We established a protocol to select patients appropriate for ICE guidance. Patients who underwent LAAO with the Watchman or Watchman FLX device (Boston Scientific, Marlborough, Massachusetts) from January 2018 to March 2022 at a large United States center were included. The novel protocol prospectively selected TEE or ICE guidance beginning in January 2020; previous LAAO procedures were retrospectively included. ICE was selected for patients with uninterrupted anticoagulation and appropriate LAA anatomy, renal function, and moderate sedation tolerance. In-hospital outcomes with successful implantation without conversion to TEE guidance, no peridevice leak, and no procedural complications were compared. Composite 1-year outcome included freedom from peridevice leak, device-related thrombus, stroke, and all-cause mortality. A total of 234 patients were included; the mean age was 76.1 ± 8.3 years old, and 42.3% were female. ICE guidance was used for 63 procedures; TEE guidance was used for 171 procedures. For the composite outcome, ICE-guided LAAO was superior to TEE-guided LAAO (risk difference 0.102, 96.8% vs 86.5%, 95% confidence interval 0.003 to 0.203, p = 0.029). In comparison to the TEE-guided group, ICE-guided procedures were shorter (89.1 ± 26.3 vs 99.8 ± 30.0 min, p = 0.0087) with less general anesthesia (26.6% vs 98.8%, p