Intracardiac echocardiography demonstrated non-inferiority compared to transesophageal echocardiography for LAA thrombus screening and peri-procedural stroke risk (OR 0.64; 95% CI 0.15-2.72).
Meta-Analysis (n=7,251)
Does Intracardiac Echocardiography (ICE) prevent peri-procedural stroke and detect LAA thrombus as effectively as Transesophageal Echocardiography (TEE) in atrial fibrillation ablation candidates?
ICE demonstrates non-inferiority to TEE for LAA thrombus screening and peri-procedural stroke prevention in AF ablation candidates, offering a viable alternative without TEE-associated side effects.
Effect estimate: OR 0.64 (95% CI 0.15-2.72)
Abstract Background and aims Accurate exclusion of Left Atrial Appendage (LAA) thrombus is critical to preventing cardioembolic stroke during atrial fibrillation (AF) ablation. While Transesophageal Echocardiography (TEE) is the gold standard for screening, it carries risks of esophageal injury and requires sedation. Intracardiac Echocardiography (ICE) has emerged as an alternative, yet its safety regarding peri-procedural stroke remains unclear. This meta-analysis evaluates the comparative efficacy of ICE versus TEE in detecting LAA thrombus and preventing peri-procedural cerebrovascular events in AF ablation candidates. Methods A systematic search of four electronic databases was conducted until October 2025. Studies reporting intracardiac thrombus detection rates or periprocedural complications were included. A random-effects model was used for all analyses, conducted in RevMan. Results The analysis included data from twelve studies comprising 7,251 patients. There was no significant difference in peri-procedural stroke risk between TEE and ICE (OR: 0.64; 95% Confidence Interval CI: 0.15, 2.72; I2 = 0%). Moreover, there was no significant difference in the risk of bleeding or pericardial effusion/tamponade between TEE and ICE (OR: 1.14; 95% CI: 0.74, 1.77; I2 = 0%) and (OR: 1.26; 95% CI: 0.70, 2.29; I2 = 0%). Notably, the thrombus detection rate was similar among the two modalities: (OR: 0.98; 95% CI: 0.35, 2.74; I2 = 56%). Conclusions ICE demonstrated non-inferiority compared to TEE for LAA thrombus screening, with similar cerebrovascular events risk. Thus, ICE emerges as a viable alternative to TEE for stroke risk mitigation that avoids TEE side effects. Future studies investigating the cost-effectiveness and real-world application of ICE are recommended. Conflict of interest Zeyad Bady: nothing to disclose; Mahmoud Refaey: nothing to disclose.; Ahmed Talkhan: nothing to disclose; Ahmed Nasreldein: nothing to disclose.
Bady et al. (2026) conducted a meta-analysis in Atrial fibrillation ablation candidates (n=7,251). Intracardiac Echocardiography (ICE) vs. Transesophageal Echocardiography (TEE) was evaluated on Peri-procedural stroke risk (OR 0.64, 95% CI 0.15-2.72). Intracardiac echocardiography demonstrated non-inferiority compared to transesophageal echocardiography for LAA thrombus screening and peri-procedural stroke risk (OR 0.64; 95% CI 0.15-2.72).