Intracardiac Versus Transesophageal Echocardiography for Left Atrial Appendage Occlusion

Background: Intracardiac echocardiography (ICE) is increasingly used to guide left atrial appendage occlusion (LAAO) because it may reduce dependence on general anesthesia, transesophageal echocardiography (TEE) imaging personnel, and procedural resource utilization. However, comparative procedural and safety outcomes between ICE and TEE remain incompletely defined. Research Question: How does ICE compare with TEE for procedural success, procedural duration, resource utilization, and periprocedural complications during LAAO? Methods: A systematic review and meta-analysis was performed using PubMed, Embase, and Cochrane databases through December 1, 2025. Twenty-four observational studies involving 132,398 patients undergoing LAAO were included. Outcomes included procedural success, procedure time, in-lab time, cost, periprocedural complications, stroke/transient ischemic attack (TIA), pericardial effusion/tamponade, peri-device leak, and residual iatrogenic atrial septal defect (iASD). Odds ratios (OR) and mean weighted differences (MWD) with 95% confidence intervals were pooled using random-effects models. Results: Among 132,398 patients, 6,287 (4.75%) underwent ICE-guided LAAO. Procedural success was similar between ICE and TEE (98.8% vs 98.5%; OR 1.13, 95% CI 0.84-1.51; p=0.426). Procedure time was not significantly different (MWD -2.75 minutes; p=0.384), although ICE significantly reduced total in-lab time (83.7 ± 34.3 vs 110.3 ± 40.0 minutes; MWD -26.59 minutes; p<0.001). Total procedural cost was similar (MWD $2,539; p=0.207), while professional fees were lower with ICE (MWD -$5,415; p=0.008). ICE was associated with higher overall periprocedural complications (6.1% vs 5.4%; OR 1.17; p=0.031), including pericardial effusion/tamponade (2.5% vs 1.9%; OR 1.36, 95% CI 1.06 - 1.76; p=0.016) and stroke/TIA (0.56% vs 0.29%; OR 2.25, 95% CI 1.23 - 4.13; p=0.008). Residual iASD was more common with ICE (36.6% vs 27.3%; OR 1.62; p=0.002), whereas peri-device leak was similar between groups. Conclusions: ICE-guided LAAO provides comparable procedural success with meaningful reductions in in-lab time and professional resource utilization, supporting its role as an efficient alternative imaging strategy as structural heart procedure volumes continue to expand. However, ICE was also associated with increased periprocedural complications, including pericardial effusion/tamponade and stroke/TIA. Although the absolute event differences were small, these findings remain clinically relevant because LAAO is a preventive procedure performed in otherwise stable patients with a low margin for procedural risk. Continued advances in ICE technology, procedural standardization, and increasing operator experience may help mitigate these safety concerns and further define the role of ICE-guided LAAO.