Intracardiac Echocardiography Versus Transesophageal Echocardiography for Guidance of Atrial Fibrillation Ablation: A Systematic Review and Meta‐Analysis of Procedural Safety and Efficacy

Q: What is the clinical evidence from this study?

Study design: Meta-Analysis. Population: Atrial fibrillation (n=4760). Intervention: Intracardiac echocardiography (ICE) vs. Transesophageal echocardiography (TEE). Primary outcome: Cardiac tamponade (Peto OR 0.67, 95% CI 0.33-1.36).

Q: What does this research mean for the field?

Intracardiac echocardiography (ICE) is a reasonable alternative to transesophageal echocardiography (TEE) for guiding atrial fibrillation ablation, demonstrating no significant differences in periprocedural complications or total procedure duration, though current evidence certainty is low. Novelty: ClaimNovelty.SYNTHESIS. Consensus alignment: ConsensusAlignment.NEUTRAL.

Afthab Salam Kanniyan; Omer Mohammed; Arshita Wadhwa; Sruthi Sai Purnima Koduri; Nimrah Fatima; DARSHAN SHIVANNE GOWDA; Laura Marcela Romero‐Acero; Michele Nanna; Shelby Kutty

doi:10.1111/echo.70543

July 1, 2026Echocardiography

Intracardiac Echocardiography Versus Transesophageal Echocardiography for Guidance of Atrial Fibrillation Ablation: A Systematic Review and Meta‐Analysis of Procedural Safety and Efficacy

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Key result

ICE shows no difference in cardiac tamponade or complications versus TEE during AF ablation.

Peto OR 0.67
95% CI 0.33-1.36
n=4,760

Why the study?

TEE is standard for AF ablation guidance but carries instrumentation risks and logistical burdens; ICE is an alternative, but comparative evidence had not been systematically synthesized.

Does intracardiac echocardiography (ICE) improve safety or procedural efficiency compared to transesophageal echocardiography (TEE) in adults undergoing atrial fibrillation catheter ablation?

Key Points

This review aims to compare the safety and efficacy of intracardiac echocardiography (ICE) versus transesophageal echocardiography (TEE) in atrial fibrillation ablation.
Systematic review and meta-analysis of six studies, including one randomized controlled trial, with 4,760 participants.
Utilized Peto odds ratios for safety outcomes and mean differences with random-effects models for continuous outcomes.
Cohort studies included both ICE (2,616) and TEE (2,144) populations.
ICE showed no significant difference in periprocedural complications, including cardiac tamponade (OR 0.67, 95% CI 0.33-1.36) and stroke/TIA/thromboembolism (0.81, 95% CI 0.36-1.78).
Total procedure duration did not differ significantly (MD -7.11 min, 95% CI -18.82 to 4.61).
ICE was associated with shorter fluoroscopy time (MD -4.17 min, 95% CI -6.07 to -2.26).

Study Design

Type

Meta-Analysis (n=4,760)

Multicenter

Yes

Structured PICO

Does intracardiac echocardiography (ICE) improve safety or procedural efficiency compared to transesophageal echocardiography (TEE) in adults undergoing atrial fibrillation catheter ablation?

P

Population

4,760 adults undergoing atrial fibrillation catheter ablation across 6 studies comparing intracardiac and transesophageal echocardiography.

I

Intervention

Intracardiac echocardiography (ICE) for periprocedural imaging guidance

C

Comparator

Transesophageal echocardiography (TEE) for periprocedural imaging guidance

O

Outcome

Periprocedural safety (cardiac tamponade, stroke/TIA/thromboembolism, vascular complications, bleeding) and procedural efficiency (total procedure duration, fluoroscopy time)safety

Main Result

Odds Ratio: 0.67 (95% CI 0.33–1.36)

ICE appears to be a safe and efficient alternative to TEE for guiding AF ablation, though current evidence is limited by low certainty.

Limitations

Certainty of evidence was low to very low
Absence of significant differences reflects imprecision rather than demonstrated equivalence

Implication

ICE supports use as a safe TEE alternative for AF ablation guidance; leaves open efficiency questions pending higher-certainty trials.

Abstract

PURPOSE: Transesophageal echocardiography (TEE) is the standard periprocedural imaging modality for atrial fibrillation (AF) catheter ablation but carries the burden of esophageal instrumentation, frequent deep sedation, and logistical constraints. Intracardiac echocardiography (ICE) is a growing alternative, yet comparative evidence had not been systematically synthesized. This systematic review and meta-analysis compared ICE and TEE as periprocedural imaging strategies in adults undergoing AF catheter ablation, focusing on safety and procedural efficiency. METHODS: A search of PubMed, Embase, CENTRAL, and Web of Science identified six eligible studies (five cohort studies and one multicenter randomized controlled trial) enrolling 4760 participants (ICE n = 2616; TEE n = 2144). Peto odds ratios (OR) were used for dichotomous safety outcomes and mean differences (MD) with random-effects models for continuous outcomes; certainty of evidence was graded using GRADE. RESULTS: ICE was not associated with significant differences in periprocedural complications, including cardiac tamponade (Peto OR 0.67, 95% CI 0.33-1.36), stroke/TIA/thromboembolism (0.81, 0.36-1.78), vascular complications (1.22, 0.70-2.13), or bleeding (0.50, 0.22-1.12). Total procedure duration did not differ (MD -7.11 min, 95% CI -18.82 to 4.61). ICE was associated with shorter fluoroscopy time (MD -4.17 min, -6.07 to -2.26), though this was attenuated after excluding studies with combined left atrial appendage occlusion. Certainty of evidence was low to very low; the absence of significant differences reflects imprecision rather than demonstrated equivalence and should be regarded as hypothesis-generating. CONCLUSION: Within these limitations, ICE may be a reasonable alternative to TEE in appropriately selected patients at centers with established ICE expertise. PROSPERO: CRD420251239269.

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Cite This Study

Kanniyan et al. (2026) conducted a meta-analysis in Atrial fibrillation (n=4,760). Intracardiac echocardiography (ICE) vs. Transesophageal echocardiography (TEE) was evaluated on Cardiac tamponade (Peto OR 0.67, 95% CI 0.33-1.36). Intracardiac echocardiography showed no significant difference in cardiac tamponade (OR 0.67; 95% CI 0.33-1.36) or other periprocedural complications compared to TEE during AF ablation.

synapsesocial.com/papers/6a48a83589561a0c2d78eeda https://doi.org/10.1111/echo.70543