4. Discussion
Among 20 enrolled published original articles, a total of 3,610 patients (1,564 patients for ICE and 2,046 patients for TEE) were evaluated. Compared to several other meta-articles, we enrolled recent publications and single-arm studies. Meanwhile we performed a subgroup analysis for each endpoint event. Our main findings are as follows: 1) Compared with TEE group, ICE group showed comparable efficacy and safety outcomes for LAAO, including the acute procedural success rate, total procedure time, contrast volume, the fluoroscopic time and safety outcomes. 2) ICE-guided LAAO might reduce the use of contrast agent than TEE-guided LAAO in the lower proportion PAF, as well as lower proportion hypertension.
AF is an important pathogenesis of ischemic stroke, and approximately 5% of stroke patients are associated with AF per year, which leads to a high mortality and morbidity[3]. Left atrial appendage closure has been demonstrated to be an alternative to prevent stroke in patients with AF, particularly those who are intolerant to oral anticoagulants. Intraoperative imaging is a crucial factor for LAAC, and although TEE is currently the mainstream method, ICE is increasingly being used as an alternative to TEE.
In this meta-analysis, we compared the acute procedural success between the TEE and ICE groups, and similar to other studies, there was no noteworthy difference between the two groups[26-28]. Then we conducted a subgroup analysis to further compare the advantages and disadvantages of the two groups. The result shows that regardless of the subgroup, there was no significant difference in acute procedural success rate. TEE which is the gold standard imaging method for LAAO can providing clear images of the right atrium, left atrium, atrial septum and left atrial appendage anatomy for left atrial appendage occlusion, but it has some disadvantages: 1. it requires general anesthesia 2. it can damage the esophagus 3. it produces aerosols with a risk of virus transmission, etc. To explore the safety of ICE and TEE,we counted both the preprocedural complications and the long-term complications. For the short-term adverse events, the results show that ICE seems to be not-inferior to TEE for guiding LAA occlusion procedures in terms of peri-procedural complications. The results of the long‐term adverse events were likely between groups, indicating ICE had a reliable performance on safety.
Meanwhile, for procedural time and the fluoroscopic time, we recognized that the pooled rates were similar between ICE group and TEE group. TEE-guided LAAC typically requires general anesthesia, endotracheal intubation, and post-anesthesia care, thus it requires longer periods of the total in-room time and the turnaround time. But it doesn’t influence the procedural time which indicate the time from puncture to closure. Interestingly, there was no remarkable difference in the total contrast volume required between the ICE and TEE groups, but in subgroup analysis it was found that in paroxysmal AF <50% subgroup and blood pressure < 90 subgroup, the contrast volume in the ICE group was much lower than that in the TEE group.
In addition, two studies compared the cost of hospitalization between ICE group and TEE group[8, 9]. The drug and personnel cost savings associated with routine use of ICE guidance and local anesthesia may outweigh the cost of ICE catheters. Thus, the global charges (hospital charges and professional fees) were similar in the ICE and TEE groups.