Intracardiac Echocardiography vs. Transesophageal Echocardiography for Left Atrial Appendage Occlusion Guidance: A Systematic Review and Meta-Analysis

Background: Intracardiac echocardiography (ICE) is increasingly used as an alternative to transesophageal echocardiography (TEE) for guidance of left atrial appendage occlusion (LAAO), particularly to reduce dependence on general anesthesia.However, comparative evidence regarding procedural efficiency, safety, and follow-up outcomes remains heterogeneous.Objective: To compare the effectiveness and safety of ICE-guided versus TEEguided LAAO.Methods: A systematic review and meta-analysis was conducted in accordance with PRISMA 2020.PubMed/MEDLINE, Embase, Scopus, Web of Science, and the Cochrane Library were searched for comparative studies of ICE-and TEEguided percutaneous LAAO.Thirteen studies met the eligibility criteria.Outcomes included technical success, procedure duration, fluoroscopy time, contrast volume, periprocedural complications, thromboembolic events, device-related thrombus, mortality, peri-device leak, and residual iatrogenic atrial septal defect.Randomeffects models were used for quantitative synthesis.Results: Technical success was comparable between ICE and TEE (RR 1.01, 95% CI 1.00-1.02;P=0.24; I²=0%).No significant differences were observed in procedure duration (MD -7.12 minutes, 95% CI -16.69 to 2.46), fluoroscopy time, or contrast volume.Pericardial effusion/tamponade was numerically more frequent with ICE but was not statistically significant (RR 1.48, 95% CI 0.96-2.26).Bleeding, vascular complications, and device embolization were similar between groups.Stroke, device-related thrombus, and all-cause mortality also showed no significant differences.ICE was associated with a higher incidence of residual iatrogenic atrial septal defect, while significant peri-device leak and complete LAA sealing were comparable.Conclusion: ICE-guided LAAO provides technical and clinical outcomes broadly comparable to TEE-guided procedures and offers the practical advantage of reduced reliance on general anesthesia.Potential increases in pericardial effusion and residual iatrogenic atrial septal defect warrant attention, particularly during early operator experience.ICE represents a viable alternative to TEE in appropriately selected patients and experienced centers.