Intracardiac vs. Transesophageal echocardiography in left atrial appendage occlusion: real-world comparative effectiveness from a propensity-matched cohort

Background: Atrial fibrillation (AF) is the most prevalent sustained cardiac arrhythmia and is associated with a markedly increased risk of thromboembolic stroke, primarily originating from the left atrial appendage (LAA). Percutaneous left atrial appendage occlusion (LAAO) is an established alternative for stroke prevention in patients with contraindications to long-term oral anticoagulation. Transesophageal echocardiography (TEE) has traditionally guided LAAO, but intracardiac echocardiography (ICE) is increasingly adopted to facilitate conscious sedation and operator-controlled imaging. Comparative real-world safety and effectiveness data between ICE and TEE remain limited. Methods: We conducted a retrospective, multicenter cohort study using the TriNetX Research Network, comprising 112 healthcare organizations. Adult patients with atrial fibrillation who underwent percutaneous LAAO guided exclusively by ICE or TEE were identified. The primary endpoint was 30-day all-cause mortality. Secondary endpoints included pericardial effusion, stroke/cerebrovascular accident (CVA), major bleeding, acute kidney injury (AKI), device-related complications, and all-cause hospitalization or emergency department encounters, assessed at 30 and 365 days. Propensity score matching (1:1) was performed using demographics, comorbidities, medications, prior procedures, and laboratory values. Risk ratios, absolute risk differences, Kaplan-Meier analyses, and multivariable Cox proportional hazards models were used to compare outcomes. Results: Among 10,629 eligible patients, 3,930 underwent ICE-guided LAAO and 6,699 underwent TEE-guided LAAO. After propensity score matching, 3,442 patients remained in each cohort with well-balanced baseline characteristics. At 30 days, all-cause mortality was numerically lower with ICE than TEE (0.4% vs. 0.8%; RR 0.577, p = 0.085). ICE guidance was associated with significantly lower rates of pericardial effusion (2.0% vs. 2.8%; RR 0.716, p = 0.040) and reduced all-cause hospitalization or emergency department encounters (21.5% vs. 29.5%; RR 0.731, p < 0.001). Rates of stroke/CVA, major bleeding, and AKI did not differ significantly between groups. In adjusted Cox models, ICE was associated with lower hazards of pericardial effusion, stroke/CVA, and major bleeding at 30 days. At 365 days, all-cause mortality was similar between ICE and TEE (5.5% vs. 6.0%; p = 0.383). Major bleeding and all-cause hospitalization or emergency encounters were significantly lower with ICE, while other outcomes remained comparable. Conclusions: In this large real-world propensity-matched analysis, ICE-guided LAAO demonstrated comparable short-term and mid-term safety to TEE guidance, with significantly lower early pericardial effusion rates and reduced healthcare utilization. These findings support ICE as a safe and effective alternative to TEE for LAAO in experienced centers, while highlighting the importance of operator expertise and continued evaluation in prospective studies.