Intracardiac Echocardiography in Structural Heart Interventions: A Comprehensive Overview

Intracardiac echocardiography (ICE) is increasingly recognized as a valuable imaging modality in structural heart interventions, offering high-resolution, real-time visualization from within the cardiac chambers. Originally developed for electrophysiologic procedures, ICE has expanded its use across a broad spectrum of structural interventions, including atrial septal defect (ASD) and patent foramen ovale (PFO) closure, left atrial appendage occlusion (LAAO), transseptal puncture guidance, transcatheter edge-to-edge repair (TEER), balloon mitral valvuloplasty, and both mitral and tricuspid valve therapies. This review outlines the current role and technical principles of ICE, with an emphasis on catheter design, image acquisition protocols, and the emerging potential of 3D ICE. Comparisons with transesophageal echocardiography (TEE) and fluoroscopy are discussed, highlighting ICE's ability to support minimally invasive, sedation-sparing procedures while maintaining procedural precision. We provide a focused analysis of ICE-guided applications in specific clinical scenarios, emphasizing its role in anatomical assessment, device navigation, and intra-procedural monitoring. Data from recent clinical studies and registries are reviewed to assess safety, feasibility, and outcomes. Practical considerations including operator learning curve, workflow integration, and limitations such as cost and field of view are also addressed. Lastly, we explore future directions including advanced 3D imaging, fusion imaging, artificial intelligence integration, and robotic catheter systems.