Cardiac CT Versus Transesophageal Echocardiography Following Left Atrial Appendage Closure: A Systematic Review and Meta-Analysis

BACKGROUND: In the landmark WATCHMAN trials, transesophageal echocardiography (TEE) was used to evaluate peri-device leak (PDL) and device-related thrombus (DRT) after percutaneous left atrial appendage closure (LAAC). We aimed to investigate the diagnostic utility of cardiac computed tomography angiography (CCTA) compared with TEE for post-LAAC device surveillance. METHODS: We conducted a literature search of 5 electronic databases to identify studies that included patients who underwent both CCTA and TEE after LAAC. We performed a meta-analysis by pooling outcomes for residual leak (left atrial appendage patency), any PDL, large PDL (>5 mm), and DRT. RESULTS: We included 17 cohort studies with 1313 patients who underwent both CCTA and TEE after LAAC. CCTA was associated with higher odds of detecting residual leak (58.8% versus 34.6%, odds ratio, 2.26 [95% CI, 1.48–3.44], P =0.0002; I 2 =73%; 15 studies, 975 patients; moderate certainty) and any PDL (51.6% versus 35.5%, odds ratio, 1.59 [95% CI, 1.01–2.51], P =0.04; I 2 =73%; 12 studies, 870 patients; moderate certainty) when compared with TEE. There were no significant differences in the detection rates of large PDL (>5 mm) between CCTA and TEE (2.8% versus 0.8%, odds ratio, 3.12 [95% CI, 0.73–13.36], P =0.13; I 2 =0%; 5 studies, 338 patients; moderate certainty). The incidence of DRT was low (1.7%), and the detection rate did not differ between the 2 modalities (1.7% versus 1.7%, odds ratio, 1.0 [95% CI, 0.41–2.42], P =1.0; I 2 =0%; 6 studies, 584 patients; high-certainty). CONCLUSIONS: Following LAAC, CCTA had higher odds of detecting residual leak and any PDL compared with TEE, whereas there were no significant differences in the detection of large PDL (> 5mm) and DRT between the 2 modalities. The findings of this meta-analysis should provide reassurance to patients and clinicians who prefer CCTA over TEE after LAAC. While DRT and left atrial appendage patency with visible PDL are known to be associated with thromboembolism, the clinical significance of left atrial appendage patency without visible PDL is uncertain and warrants further investigation. REGISTRATION: URL: https://www.crd.york.ac.uk/PROSPERO/ ; Unique identifier: CRD42024578802.