Intracardiac Versus Transesophageal Echocardiography in Atrial Fibrillation Ablation

TEE is considered a standard imaging modality in patients undergoing atrial fibrillation ablation, with associated risks of patient discomfort and laryngeal, esophageal, and pharyngeal injury. Intracardiac Echocardiography , being an advanced imaging modality, has shown comparable in atrial fibrillation ablation. Question: To compare the fluoroscopy time and procedure time between ICE and TEE in patients undergoing atrial fibrillation ablation with pericardial effusion, stroke, and vascular events. Research Question; This study aims to synthesize the available evidence comparing intracardiac echocardiography (ICE) and transesophageal echocardiography (TEE) guidance during atrial fibrillation ablation, with a focus on procedural efficiency outcomes, including procedure time and fluoroscopy time. Method: A comprehensive search of the PubMed, Scopus, and Cochrane databases for relevant observational studies and clinical trials between 2017 and 2025. Studies in full text were included with no restriction to language articles. Screening was done using Rayyan, and were finalized according to predefined inclusion criteria. Eligibility criteria included patients (18 years or more) undergoing atrial fibrillation ablation, and patients under 18 years or not undergoing atrial fibrillation ablation were excluded. Primary outcomes included the difference in Procedural Time and Fluoroscopy Time in ICE and TEE. Secondary PE, stroke, and vascular events. A meta-analysis was performed using pooled effect estimates. Mean difference (MD) with 95% confidence intervals (CI) was calculated for continuous outcomes, while the odds ratio (OR) with 95% CI was used for dichotomous outcomes. Heterogeneity assessed using the I 2 statistic. Result: A total of 5 studies were included, comprising 4888 patients, of whom 2453 patients underwent ICE, and 2435 patients underwent TEE. For fluoroscopy time, three studies involving 1,270 patients in the ICE group and 983 patients in the TEE group demonstrated no significant difference between groups with significant heterogeneity (I 2 =99.1%). Total procedural time, reported in four studies with 1,487 ICE and 1,098 TEE patients, demonstrated no significant reduction favoring ICE, although heterogeneity was substantial (I 2 =97.6%). PE, reported in three studies including 2,134 ICE and 2,217 TEE patients, showed no significant difference ,(I 2 =0%). Stroke outcomes from four studies involving 2,351 ICE and 2,332 TEE patients also revealed no significant difference (p= 0.6228; I 2 =0%). Similarly, vascular adverse events reported in three studies showed no significant difference between groups. Conclusion: ICE demonstrated comparable safety and efficacy to TEE, showing a nonsignificant trend toward shorter procedural time compared to TEE. No significant differences in fluoroscopy time, pericardial effusion, stroke, and vascular events.