Intracardiac Echocardiography Versus Transesophageal Echocardiography for Guidance of Atrial Fibrillation Ablation: A Systematic Review and Meta‐Analysis of Procedural Safety and Efficacy

PURPOSE: Transesophageal echocardiography (TEE) is the standard periprocedural imaging modality for atrial fibrillation (AF) catheter ablation but carries the burden of esophageal instrumentation, frequent deep sedation, and logistical constraints. Intracardiac echocardiography (ICE) is a growing alternative, yet comparative evidence had not been systematically synthesized. This systematic review and meta-analysis compared ICE and TEE as periprocedural imaging strategies in adults undergoing AF catheter ablation, focusing on safety and procedural efficiency. METHODS: A search of PubMed, Embase, CENTRAL, and Web of Science identified six eligible studies (five cohort studies and one multicenter randomized controlled trial) enrolling 4760 participants (ICE n = 2616; TEE n = 2144). Peto odds ratios (OR) were used for dichotomous safety outcomes and mean differences (MD) with random-effects models for continuous outcomes; certainty of evidence was graded using GRADE. RESULTS: ICE was not associated with significant differences in periprocedural complications, including cardiac tamponade (Peto OR 0.67, 95% CI 0.33-1.36), stroke/TIA/thromboembolism (0.81, 0.36-1.78), vascular complications (1.22, 0.70-2.13), or bleeding (0.50, 0.22-1.12). Total procedure duration did not differ (MD -7.11 min, 95% CI -18.82 to 4.61). ICE was associated with shorter fluoroscopy time (MD -4.17 min, -6.07 to -2.26), though this was attenuated after excluding studies with combined left atrial appendage occlusion. Certainty of evidence was low to very low; the absence of significant differences reflects imprecision rather than demonstrated equivalence and should be regarded as hypothesis-generating. CONCLUSION: Within these limitations, ICE may be a reasonable alternative to TEE in appropriately selected patients at centers with established ICE expertise. PROSPERO: CRD420251239269.