Left atrial appendage closure with the Watchman device using intracardiac vs transesophageal echocardiography: Procedural and cost considerations

Abstract

Imaging guidance for left atrial appendage (LAA) closure (LAAC), conventionally consists of transesophageal echocardiography (TEE) and fluoroscopy under general anesthesia (GA). Intracardiac echocardiography (ICE) can eliminate the need for GA, and expedite procedural logistics, and reduce the patient experience to a simple venous puncture. To define optimal ICE views and compare procedural parameters and cost of ICE vs TEE during LAAC with the Watchman device. Optimal ICE views of the LAA for Watchman implant were delineated using Carto-Sound and 3D rendition of the LAA in 6 patients. Procedural and financial parameters of 104 consecutive patients with standard indications for LAAC undergoing Watchman implant using ICE guidance through a single trans-septal puncture (n=53, 51%) were compared with those of TEE-guided implants (n=51, 49%) in 3 centers. Clinical characteristics were similar between the two groups. Total in-room, turnaround and fluoroscopy times were all shorter using ICE (p<0.05) under local anesthesia compared to the TEE group. Implant success was 100% in both groups without peri-device leaks or procedural complications. Follow-up TEE showed no significant peri-device leak in both groups. Total hospital charges for ICE with local anesthesia vs TEE were similar as were total hospital direct and indirect costs. Professional fees were significantly lower with ICE and local anesthesia than with TEE as the charge of anesthesia staff was avoided. ICE-guided Watchman implant is safe, feasible, and comparable in cost to TEE during LAAC with a Watchman device while avoiding GA and expediting the procedure turnaround.