Purpose: Left atrial appendage occlusion (LAAO) with the Watchman FLX device (Boston Scientific, Marlborough, Massachusetts) is commonly performed with the use of transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE). Limited data is available on the added value of ICE imaging to TEE guidance. Our objective was to evaluate the impact of adding ICE imaging to TEE for Watchman FLX implants.
Material and Methods: Watchman FLX implants (October 2020 - March 2023) were retrospectively analyzed. Data including procedural equipment, imaging modality, duration, and 45-day outcomes were collected. TEE was routinely used at the start of these procedures by all 4 providers. ICE was routinely added by 2 providers at the start. Data were analyzed based on imaging modality (TEE, ICE+TEE, or ICE alone). Procedures were also categorized as simple or complex. Procedures requiring one trans-septal access, one sheath, and one device for successful LAAO were defined as simple. All others requiring more steps and equipment were defined as complex.
Results: A total of 669 procedures were performed: 62% TEE, 37% ICE+TEE, and 1% ICE alone. Average procedure times were 40 minutes - TEE group, 56 minutes - ICE+TEE group, and 42 minutes - ICE alone group. Procedures were more likely to be in the simple category with ICE+TEE compared to TEE alone (22% vs 16%, p = 0.048). In the complex category, the largest group consisted of those requiring a single trans-septal access, a single sheath, and multiple different device sizes to achieve successful LAAO. In this group requiring multiple devices, there were more patients in the TEE group compared to the ICE+TEE group (17% vs 10%, p = 0.011). On 45-day post procedure imaging, 2 patients in the TEE group and 3 patients in the ICE+TEE had thrombus (0.48% vs 1.19%, p = 0.372). Four patients had meaningful leaks (>3mm in size) in the TEE group, and no patients had leaks >3mm in the ICE+TEE group (0.97% vs 0%, p = 0.303). There were no intra-procedural deaths, strokes, or pericardial effusions requiring surgery.
Conclusions: In a large group of Watchman FLX implants, the addition of ICE imaging to TEE guidance took more time (16 minutes on average) but was associated with a simpler procedure. Among the complex cases, addition of ICE was associated with fewer cases requiring multiple different devices suggesting better sizing of the left atrial appendage.
