Intracardiac echocardiography is a safe, non-inferior alternative to transesophageal echocardiography for atrial fibrillation ablationIntracardiac echocardiography shows safety and efficiency in atrial fibrillation procedures

This meta-analysis evaluated the comparative safety and efficacy of intracardiac echocardiography (ICE) versus transesophageal echocardiography (TEE) in patients undergoing catheter ablation for atrial fibrillation (AF), with or without left atrial appendage closure (LAAC). The study included a large population of 7,671 patients to determine if ICE could serve as a viable alternative to TEE during these complex cardiac procedures.

The study compared the two imaging modalities across several critical safety and procedural metrics. The primary focus was on identifying whether the transition from TEE to ICE impacts major complications such as cardiac tamponade, stroke, or vascular injuries. Additionally, the analysis examined procedural metrics including radiation exposure, fluoroscopy time, and total procedure duration, as well as the ability to detect pre-procedure left atrial appendage (LAA) thrombi.

Regarding major safety outcomes, the meta-analysis reported no significant difference between ICE and TEE for cardiac tamponade risk (RR 0.86; 95% CI 0.44-1.66; P = 0.39). Similarly, there was no significant difference in the incidence of stroke or transient ischaemic attack (RR 1.00; 95% CI 0.39-2.55; P = 0.57). Vascular complications also showed no significant difference between the two groups (RR 0.80; 95% CI 0.51-1.25; P = 0.37). These results suggest that ICE provides comparable safety profiles to TEE for the primary risks associated with AF ablation.

In terms of procedural efficiency and technical metrics, ICE was associated with a lower radiation dose (SMD -0.47; 95% CI -0.90 to -0.04; P = 0.03) and a lower fluoroscopy time (reduction of 4.25 min; 95% CI -6.01 to -2.49; P < 0.01) compared to TEE. Furthermore, a significantly lower procedure duration was observed specifically in the subgroup of patients undergoing combined AF ablation and LAAC (MD -19.56 min; 95% CI -24.15 to -14.97; P < 0.01) when using ICE.

One notable finding regarding clinical utility was the detection of pre-procedure LAA thrombi. The results indicated a lower rate of thrombus detection in the ICE group (RR 0.32; 95% CI 0.11-0.94; P = 0.04). This suggests that while ICE is a safe and effective alternative for procedural guidance, TEE remains a highly effective tool for specific tasks such as thrombus detection.

These results indicate that ICE is a safe, effective, and non-inferior alternative to TEE for patients undergoing AF ablation with or without LAAC. While TEE remains an effective tool for detecting LAA thrombus, ICE may offer advantages in terms of reduced radiation and shorter procedure times. Clinical decisions regarding the choice of imaging modality may depend on the specific procedural goals, such as whether thrombus detection is a primary requirement for the individual patient.

Methodological limitations were not reported. However, the large sample size of 7,671 patients provides a robust basis for the findings regarding safety and procedural efficiency. Questions remain regarding the specific reasons for the lower thrombus detection rate in the ICE group and whether this difference is clinically significant in the context of LAAC procedures.