# Systematic evaluation and meta-analysis of transcardiac intracavitary and transesophageal echocardiography-guided left atrial appendage occlusion surgery

## TL;DR

This study compares two imaging techniques for heart surgery, finding they are equally safe but differ in efficiency and cost depending on patient factors.

## Contribution

A systematic evaluation and meta-analysis of ICE and TEE-guided LAAO, highlighting patient-specific and device-specific factors affecting outcomes.

## Key findings

- ICE and TEE have similar technical success and complication rates.
- ICE reduces procedure time in younger patients and with certain devices.
- ICE lowers professional costs but increases hospitalization costs with geographic variation.

## Abstract

To systematically evaluate the differences in safety, efficacy, and economics between intracardiac ultrasound (ICE) and transesophageal echocardiography (TEE)-guided LAAO (LAAO), and to provide an evidence-based rationale for the selection of clinical image-guided modalities.

PubMed, Embase, Cochrane Library, Web of Science and Wanfang databases were searched to include randomized controlled trials and observational studies comparing ICE with TEE-guided LAAO, strictly following PRISMA guidelines. Two investigators independently screened the literature, extracted data and assessed the risk of bias (ROBINS-I and Cochrane tools). Meta-analysis was performed using RevMan 5.4.1, and the outcome indicators included technical success, procedure time, contrast dose, fluoroscopy time, complications, and economic parameters, and subgroup analyses were performed to explore the effects of factors such as patient characteristics and instrument type.

A total of 16 studies were included.There was no significant difference between ICE and TEE in terms of technical success (RR = 1.01,95% CI 1.00–1.02, P = 0.24) and total risk of physical complications (RR = 0.94,95% CI 0.82–1.09, P = 0.43). Subgroup analysis showed:

ICE significantly reduced operative time in the subgroups of single-center studies (MD = −7.28 min, 95% CI: −9.46 to −5.10, P < 0.001), with AcuNav catheter (MD = −3.21 min, 95% CI: −6.20 to −0.19, P = 0.04), and patients aged <75 years (MD = −15.89 min, 95% CI: −18.95 to −12.82, P < 0.001); the use of multi-seal devices was associated with a significant reduction in contrast agent volume (MD = −21.69 mL, 95% CI: −31.44 to −11.94, P < 0.001).

In the subgroup with a hypertension proportion <90%, ICE shortened both operative time (MD = −12.00 min, 95% CI: −15.08 to −8.92, P < 0.001) and fluoroscopic time (MD = −9.32 min, 95% CI: −14.26 to −4.37, P = 0.003); however, operative time was prolonged in the ICE group for patients with a proportion of paroxysmal atrial fibrillation ≥50% (MD = 14.20 min, 95% CI: 7.60–20.80, P < 0.001).

ICE reduced professional/anesthesia-related costs (MD = -$2,654, P < 0.001) but increased hospitalization costs by approximately 17.8%, with notable geographic heterogeneity in total costs (comparable in the United States, but potentially higher for ICE in China based on existing cost structures). Sensitivity analyses showed good stability of the results, with heterogeneity (I2 > 90%) mainly stemming from differences in study design and device type.

The core clinical outcomes (success and safety) of ICE and TEE in LAAO are equivalent, but operational efficiency is moderated by patient age, LV morphology, and device design. ICE is recommended for young, anatomically simple patients at high risk for anesthesia, and individualized decision-making needs to be optimized with team experience and health economic assessment. Future multicenter RCTs and cost-utility analyses are needed to validate long-term benefits.

PROSPERO CRD42024626272.