Abstract Body (Do not enter title and authors here):
Background: As left atrial appendage closure (LAAC) becomes more widely adopted for stroke prevention in patients with atrial fibrillation, optimizing peri-procedural imaging has gained increasing clinical relevance. While transesophageal echocardiography (TEE) remains the standard imaging modality, intracardiac echocardiography (ICE) has emerged as a viable alternative. This umbrella review evaluated whether ICE provides comparable procedural outcomes to TEE and examined differences in safety and post-procedural complications based on the current evidence.

Methods: To identify relevant studies for inclusion in this umbrella review, a comprehensive search was conducted across databases, including PubMed, Cochrane Library, and Google Scholar. The GRADE (Grading of Recommendations, Assessment, Development and Evaluations) method, a widely accepted tool for assessing the quality of evidence and strength of recommendations in systematic reviews, was utilized to assess the overall certainty of the evidence comprehensively. Furthermore, the quality of the included reviews underwent evaluation by applying the AMSTAR 2 and the New Castle Ottawa scale.

Results: This review incorporates findings from seven systematic reviews and meta-analyses. In terms of procedural success, the analysis showed no significant difference between intracardiac echocardiography (ICE) and transesophageal echocardiography (TEE) (RR [95% CI]: 1.01 [1.00, 1.02], I2: 0%, p-value: 0.21). Regarding peri-procedural complications, the analysis indicated that ICE was associated with a significantly lower risk compared to TEE (RR [95% CI]: 0.79 [0.67, 0.94], I2: 0%, p-value: 0.008). Regarding the residual interatrial septal defects (IASDs), the analysis revealed that ICE was linked to a significantly higher risk of residual IASDs compared to TEE (RR [95% CI]: 1.97 [1.45, 2.68], I2: 0%, p-value: <0.0001).

Conclusion: In conclusion, ICE is a potentially beneficial substitute for TEE in the context of LAAC, as it decreases overall complications. However, whereas literature provides evidence for the advantages of ICE, comparative studies demonstrate that ICE and TEE have equal efficacy and safety profiles. This highlights the need for additional future evidence-based trials to evaluate each strategy comparative advantages in LAAC procedures thoroughly.