Echocardiographic Guidance for Percutaneous Left Atrial Appendage Occlusion: A Systematic Review of Outcomes in High-Risk Populations Including Chronic Liver Disease and Prior Gastrointestinal Bleeding

<b>Background</b>: Echocardiographic imaging has become central to planning and guiding percutaneous left atrial appendage occlusion (LAAO), particularly in patient populations in whom long-term anticoagulation is unsuitable. This systematic review synthesizes current evidence on transesophageal (TEE) and intracardiac echocardiography (ICE) guidance during LAAO, with special emphasis on outcomes in high-risk cohorts, including chronic liver disease (CLD) and prior gastrointestinal (GI) bleeding. <b>Methods</b>: Following PRISMA 2020 guidelines, four databases (PubMed, Scopus, Web of Science, and Cochrane CENTRAL) were searched up to 5 December 2025. Eligible studies included adult patients with atrial fibrillation (AF) undergoing percutaneous LAAO with intraprocedural echocardiographic guidance. Eight studies (<i>n</i> = 1739 patients) met the inclusion criteria. Data were synthesized qualitatively due to heterogeneity across devices, imaging protocols, and outcomes. <b>Results</b>: TEE was the predominant imaging modality (62.5%), providing high spatial resolution for transseptal puncture, device positioning, and peri-device leak (PDL) assessment. ICE-guided LAAO (25.0%) was associated with high procedural success and favorable safety profiles in selected observational cohorts, while reducing anesthesia requirements and fluoroscopy time. Across all studies, procedural success ranged from 93 to 100%, with low rates of major complications. Reported follow-up durations varied substantially across studies and were predominantly short- to mid-term, limiting assessment of long-term device-related outcomes. Evidence specific to patients with chronic liver disease and prior gastrointestinal bleeding was limited, with only two included studies directly evaluating these populations, while remaining insights were extrapolated from broader LAAO cohorts. In high-risk groups, LAAO remained feasible: cirrhotic patients demonstrated high implantation success with acceptable bleeding profiles, while patients with prior GI bleeding showed low recurrence after closure. <b>Conclusions</b>: Both TEE and ICE provide reliable intraprocedural imaging for LAAO, with ICE offering workflow and safety advantages in patients unsuitable for general anesthesia. The available evidence suggests that LAAO is a feasible and potentially safe therapeutic option in selected patients with CLD and prior GI bleeding, although direct data remain limited. Future studies should compare imaging modalities prospectively in high-risk cohorts and evaluate emerging 3D/4D ICE technologies.