Intracardiac vs. transesophageal echocardiography in patients undergoing ablation for atrial fibrillation: a systematic review and meta-analysis.

Abstract

Aims: Intracardiac echocardiography (ICE) is a valuable, real-time imaging tool in structural cardiology and electrophysiology, performed without general anaesthesia. 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 vs. ICE.

Methods and results: 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. We included eight studies involving 7671 patients, of whom 3903 (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 transient ischaemic attack (RR 1.00; 95% CI 0.39-2.55; P = 0.57), and 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 min; 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 min; 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.