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BACKGROUND Intracardiac echocardiography (ICE) is a valuable, real-time imaging tool in structural cardiology and electrophysiology, performed without general anesthesia. However, its safety compared to transesophageal echocardiography (TEE) remains unclear. OBJECTIVE To conduct a meta-analysis evaluating outcomes of catheter ablation for atrial fibrillation (AF) with or without left atrial appendage closure (LAAC) guided by TEE versus ICE. METHODS Databases were searched for studies comparing ICE with TEE guidance during AF ablation ± LAAC. Outcomes were pooled using the Inverse-Variance (IV) random-effects model in R, with risk ratios (RRs) for dichotomous variables and mean or standardized mean differences (MD or SMD) for continuous variables, and 95% confidence intervals (CIs) reported. RESULTS We included 8 studies involving 7,671 patients, of whom 3,903 (50.9%) underwent procedures with ICE guidance. There were no significant differences between groups in cardiac tamponade risk (RR 0.86; 95% CI 0.44-1.66; p = 0.39), stroke or TIA (RR 1.00; 95% CI 0.39-2.55; p = 0.57), vascular complications (RR 0.80; 95% CI 0.51-1.25; p = 0.37). ICE was associated with lower pre-procedure LAA thrombus detection (RR 0.32; 95% CI 0.11-0.94; p = 0.04), radiation dose (SMD -0.47; 95% CI -0.90 to -0.04; p = 0.03), and fluoroscopy time (-4.25 mins; 95% CI -6.01 to -2.49; p < 0.01) but the procedure duration was significantly lower only in combined AF ablation + LAAC (MD -19.56 mins; 95% CI -24.15 to -14.97; p < 0.01). CONCLUSION This meta-analysis indicates that ICE is a safe, effective, and non-inferior alternative to TEE for patients undergoing AF ablation ± LAAC. However, TEE remains an effective tool for detecting LAA thrombus.
