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.