Evaluating the role of transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE) in left atrial appendage occlusion: a meta-analysis



Intracardiac echocardiography (ICE) is increasingly common among periprocedural imaging modalities used during complex cardiac procedures. We sought to perform a meta-analysis comparing transesophageal echocardiography (TEE) and ICE in endocardial left atrial appendage occlusion (LAAO).


We searched PubMed and Google Scholar regarding abstracts and manuscripts using keywords: atrial fibrillation, left atrial appendage occlusion, Watchman, Amplatzer Cardiac Plug, Amulet, intracardiac echocardiography, and transesophageal echocardiography from their inception to July 12, 2019. Data extraction was performed using standard form for the following: title, year of publication, sample size, comorbid conditions, LAAO device, type of pre-procedural imaging, intraprocedural imaging, and clinical outcomes including the following: acute procedural success, fluoroscopy, and total procedure time and complications.


A total of 42 relevant studies were screened resulting in inclusion of 8 observational studies comparing TEE and ICE in endocardial LAAO. Outcomes assessed including procedural success (RR 1.00, 95% CI (0.97–1.03, p = 0.98)), complications (RR 0.77, 95% CI (0.52 to 1.15, p = 0.20)), fluoroscopy time (mean difference − 0.40, 95% CI (−3.12–2.32, p = 0.77)), and procedural time (mean difference − 8.02, 95% CI (−22.81 to 6.76, p = 0.29)) were found to be similar between both groups.


While TEE is the gold standard for perioperative imaging with LAAO, ICE is a feasible and safe alternative that reduces exposure to general anesthesia and associated potential risks.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5


  1. 1.

    Kim DY, Shin SY, Kim JS, Kim SH, Kim YH, Lim HE. Feasibility of intracardiac echocardiography imaging from the left superior pulmonary vein for left atrial appendage occlusion. Int J Cardiovasc Imaging. 2018;34:1571–9. https://doi.org/10.1007/s10554-018-1374-5.

    Article  PubMed  Google Scholar 

  2. 2.

    Korsholm K, Jensen JM, Nielsen-Kudsk JE. Intracardiac echocardiography from the left atrium for procedural guidance of transcatheter left atrial appendage occlusion. JACC Cardiovasc Interv. 2017;10(21):2198–206. https://doi.org/10.1016/j.jcin.2017.06.057.

    Article  PubMed  Google Scholar 

  3. 3.

    Frangieh AH, Alibegovic J, Templin C, Gaemperli O, Obeid S, Manka R, et al. Intracardiac versus transesophageal echocardiography for left atrial appendage occlusion with watchman. Catheter Cardiovasc Interv. 2017;90(2):331–8. https://doi.org/10.1002/ccd.26805.

    Article  PubMed  Google Scholar 

  4. 4.

    Berti S, Pastormerlo LE, Santoro G, Brscic E, Montorfano M, Vignali L, et al. Intracardiac versus transesophageal echocardiographic guidance for left atrial appendage occlusion: the LAAO Italian Multicenter Registry. JACC Cardiovasc Interv. 2018;11(11):1086–92. https://doi.org/10.1016/j.jcin.2018.05.008.

    Article  PubMed  Google Scholar 

  5. 5.

    Iwasawa J, Enomoto Y, Sharma D, et al. Abstract 16647: implantation of the watchman left atrial appendage closure device: a comparison of TEE-guidance vs ICE-guidance. Circulation. 2016;134(Suppl 1):–A16647.

  6. 6.

    Reis L, Paiva L, Costa M, Silva J, Teixeira R, Botelho A, et al. Registry of left atrial appendage closure and initial experience with intracardiac echocardiography. Rev Port Cardiol. 2018;37:763–72. https://doi.org/10.1016/j.repc.2018.03.009.

    Article  PubMed  Google Scholar 

  7. 7.

    Nielsen-Kudsk JE, Berti S, De Backer O, et al. Use of intracardiac compared with transesophageal echocardiography for LAA occlusion in the Amulet Observational Study. J Am Coll Cardiol Intv. 2019;12:1030–9. https://doi.org/10.1016/j.jcin.2019.04.035.

    Article  Google Scholar 

  8. 8.

    Hemam ME, Kuroki K, Schurmann PA, Dave AS, Rodríguez DA, Sáenz LC, et al. Left atrial appendage closure with the Watchman device using intracardiac vs transesophageal echocardiography: procedural and cost considerations. Heart Rhythm. 2019;16:334–42. https://doi.org/10.1016/j.hrthm.2018.12.013.

    Article  PubMed  PubMed Central  Google Scholar 

  9. 9.

    Stang A. Critical evaluation of the Newcastle-Ottawa scale for the assessment of the quality of nonrandomized studies in meta-analyses. Eur J Epidemiol. 2010. https://doi.org/10.1007/s10654-010-9491-z.

  10. 10.

    DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7(3):177–88. https://doi.org/10.1016/0197-2456(86)90046-2.

    CAS  Article  PubMed  Google Scholar 

  11. 11.

    Higgins JP, Altman DG, Gotzsche PC, et al. The Cochrane Collaboration’s tool for assessing risk of bias in randomised trials. BMJ. 2011;343:d5928. https://doi.org/10.1136/bmj.d5928.

    Article  PubMed  PubMed Central  Google Scholar 

  12. 12.

    Enriquez A, Saenz LC, Rosso R, et al. Use of intracardiac echocardiography in interventional cardiology working with the anatomy rather than fighting it. Circulation. 2018. https://doi.org/10.1161/CIRCULATIONAHA.117.031343.

Download references

Author information



Corresponding author

Correspondence to Dhanunjaya Lakkireddy.

Ethics declarations

Conflict of interest

DL: Consultant to Johnson & Johnson, Abbott, Biotronik, Pfizer, Boston Sci.

RG: Consultant/speaker: Abbott Medical, Boston Scientific, Zoll Medical, Pfizer, Bristol Myers Squibb; Physician advisor: HealthTrust PG, Abiomed.

Additional information

Publisher’s note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Akella, K., Murtaza, G., Turagam, M. et al. Evaluating the role of transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE) in left atrial appendage occlusion: a meta-analysis. J Interv Card Electrophysiol 60, 41–48 (2021). https://doi.org/10.1007/s10840-019-00677-x

Download citation


  • Transesophageal echocardiogram
  • TEE
  • Intracardiac echocardiography
  • ICE
  • LAAO
  • Left atrial appendage occlusion
  • Watchman
  • Amulet
  • ACP