Comparative Outcomes of ICE Versus TEE /Fluoroscopy Guidance Transseptal Puncture in LA Procedures: A Systematic Review and Meta‐Analysis

Figures

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  FIGURE 1. PRISMA Flow Diagram.

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  FIGURE 2. Central illustration.

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  FIGURE 3. Risk of bias assessment of included studies. (a) Traffic‐light plot showing risk of bias judgments for each included study across the assessed domains: Randomization/confounding, deviations from intended interventions, missing outcome data, outcome measurement, and selective reporting. Each colored square represents the risk judgment for that domain (green = low risk, orange = some concerns, red = high risk). (b) Summary plot showing the overall proportion of domains across all studies judged as low risk, some problems, or high risk.

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  FIGURE 4. Forest plots of primary outcomes comparing ICE‐guided versus TEE/fluoroscopy‐guided transseptal puncture in left atrial procedures. (a) Fluoroscopy time. (b) Radiation dose. (c) First‐pass success. (d) Puncture time. (e) Total procedure time. (f) Cardiac tamponade. (g) Pericardial effusion. (h) Composite major adverse events (MAE). Each panel displays individual study effect estimates with 95% confidence intervals (horizontal lines), pooled summary estimates (black diamonds), and a vertical reference line (0 for mean differences, 1 for hazard ratios). Effect measures are expressed as mean difference (MD) for continuous outcomes and hazard ratio (HR) for binary outcomes. Study names are shown on the left, effect estimates with 95% CI on the right, and heterogeneity statistics (I 2 and p‐value) are reported for each pooled analysis.

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  FIGURE 5. Funnel plots of primary outcomes comparing ICE‐guided versus TEE/fluoroscopy‐guided transseptal puncture. (a) Fluoroscopy time. (b) Radiation dose. (c) First‐pass success. (d) Puncture time. (e) Total procedure time. (f) Cardiac tamponade. (g) Pericardial effusion. (h) Composite major adverse events (MAE). Each panel displays study‐level effect sizes plotted against their standard errors. The dashed red vertical line represents the overall pooled effect size, and the dashed gray diagonal lines outline the expected 95% confidence limits of the funnel. Symmetry around the pooled estimate suggests the absence of small‐study or publication bias, whereas asymmetry may indicate potential bias.

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  FIGURE 6. Sensitivity and robustness analyses of pooled estimates for fluoroscopy time. (a) Leave‐one‐out influence analysis showing the effect of omitting each study on the overall pooled mean difference (MD). Horizontal lines represent 95% confidence intervals of the pooled estimate after exclusion of the indicated study. The dashed vertical line indicates the overall pooled effect including all studies. (b) Bubble plot of study‐level mean differences against year of publication. Bubble size is proportional to study weight in the meta‐analysis, and color indicates procedural subgroup (atrial fibrillation ablation vs. left atrial appendage occlusion). The dashed horizontal line denotes the overall pooled effect.