Outcomes of Intracardiac Versus Transesophageal Echocardiography to Guide Left Atrial Appendage Occlusion: A Real-World Propensity-Matched Study.

Intracardiac echocardiography (ICE) and transesophageal echocardiography (TEE) are both used to guide left atrial appendage occlusion (LAAO). Earlier comparative analyzes predate widespread adoption of 3-dimensional ICE, and ICE was often reserved for patients with comorbidities precluding TEE. With continued technological advancements and increasing adoption of ICE, contemporary real-world comparisons are warranted. We conducted a large propensity-matched analysis using the TriNetX database to compare early outcomes between ICE- and TEE-guided LAAO from 2015 through 2025. Adults undergoing LAAO were identified using procedural codes, and 1:1 propensity score matching yielded 6,357 patients in each group. The primary outcome was major adverse events (MAE), defined as a composite of all-cause mortality, stroke, myocardial infarction, bleeding, pericardial effusion, cardiac arrest, and vascular complications. Secondary outcomes included pericardiocentesis, device-related thrombus, and peri-device leak at 7 and 45 days. At 7 days, ICE guidance was associated with a lower risk of MAE compared with TEE (766 vs 937 events; HR 0.81, 95% CI 0.74 to 0.89; p <0.0001), as well as lower rates of stroke and pericardial effusion. At 45 days, ICE remained associated with lower MAE risk (1,040 vs 1,193 events; HR 0.87; p = 0.0005), stroke, cardiac arrest, and pericardial effusion. Pericardiocentesis occurred more frequently in the ICE cohort. There were no significant differences in bleeding, device-related thrombus, peri-device leak, or mortality between groups. In conclusion, ICE-guided LAAO was associated with fewer early composite adverse events compared with TEE guidance, with similar mortality and device-related complication rates. These findings support the expanding use of ICE as an effective alternative imaging modality for LAAO.