Atrial fibrillation (AF) is the most common cardiac arrhythmia in adults. The left atrial appendage (LAA) is the most likely source of thrombus formation in patients with non-valvular atrial fibrillation (NVAF). Left atrial appendage closure (LAAC) represents an effective alternative to NOAC in patients with NVAF. Expert consensus documents recommend intraprocedural imaging by means of either transesophageal echocardiography (TEE) or intracardiac echocardiography (ICE) in addition to standard fluoroscopy to guide LAAC. TEE-guided LAAC usually requires general anesthesia. The ICE technique is a “minimalist approach”, without general anesthesia, but ICE imaging techniques are not yet simplified and standardize, and the ICE may result in inferior image quality compared with that of TEE. Another “minimalist approach” can be the use of ICE via the esophageal route (ICE-TEE), that jet is validated to identify the presence of LAA thrombi in patients and to perform other procedures. In our cath laboratory ICE-TEE to guide LAAC is used in some complex patients. Indeed, our single center experience suggests that ICE-TEE could be a good alternative imaging technique to guide LAAC procedure without general anesthesia.

Background. The Lambre is a plug occluder for left atrial appendage closure (LAAC) in patients with atrial fibrillation (AF), but direct comparisons of the most used Watchman FLX and Lambre devices are lacking. Objectives. To compare the safety and efficacy of Lambre and the well-established Watchman FLX occluder for left atrial appendage (LAA) closure Methods. Between January 2023 and April 2025, a cohort of 253 consecutive patients who underwent LAAC with Lambre or Watchman FLX at Umberto I Hospital of Siracusa were included. The primary safety endpoint included major peri-procedural complications while the primary efficacy endpoint included all cause stroke, cardiovascular/unexplained death, systemic embolism and bleedings at a mean follow up of 12 months. 1:1 propensity score matching (PSM) was performed. Results. After PSM, 152 patients were included: Lambre group (n=76) and Watchman FLX group (n=76). The mean CHA2DS2-VASc score was 4.5 ± 1.3 (Lambre) vs. 4.5 ± 1.4( Watchman FLX), p=0.97; and the HAS-BLED score was 2.7 ± 0.9 vs. 2.7± 0.8, p=0.97. At a mean follow-up of 12 months, the primary efficacy endpoint (14.9% vs. 12.5%; HR, 1.57; 95% CI, 0.52–4.72; P = 0.77) and the primary safety endpoint (3.9% vs. 2.6%; HR, 1.51; CI 0.25-9.03; P=1) were similar between groups. Conclusions. LAAC with the Lambre device has demonstrated similar efficacy and safety to the Watchman devices. In a high-volume center, experienced operators, using both singleand double-element devices, can adopt a customized strategy based on each patient’s anatomy and achieve 100% successful left atrial closure.