Safety and efficacy of intracardiac echocardiography in atrial fibrillation ablation: a meta-analysis

AIMS: Intracardiac echocardiography (ICE) is increasingly incorporated into atrial fibrillation (AF) ablation workflows, enabling real-time anatomic guidance and procedural precision. Nevertheless, ICE utilization shows substantial geographic variability, and its clinical benefit remains incompletely understood. This meta-analysis evaluated the efficacy, safety, and procedural performance of ICE-guided vs. non-ICE-guided AF ablation. METHODS AND RESULTS: MEDLINE, the Cochrane Library, and Scopus were systematically searched through 3 August 2025. Three reviewers independently performed study selection, data extraction, and risk-of-bias assessment. Random-effects models were used to pool data from 44 AF ablation studies comprising 482 043 patients. ICE guidance was associated with lower odds of any complication (OR 0.69; 95% CI 0.53-0.89), including significant reductions in cardiac tamponade (OR 0.58; 95% CI 0.53-0.62) and mortality (OR 0.21; 95% CI 0.16-0.27). ICE-guided ablation was also associated with shorter total procedure and fluoroscopy times, reduced radiation exposure, and lower contrast agent utilization. Atrial tachyarrhythmia (AT) recurrence did not differ between groups (OR 0.92; 95% CI 0.79-1.06). However, ICE use was associated with higher odds of first-pass pulmonary vein isolation (OR 1.62; 95% CI 1.09-2.41) and successful isolation of all pulmonary veins at the end of the procedure (OR 2.12; 95% CI 1.37-3.27), and lower odds of repeat ablation (OR 0.65; 95% CI 0.59-0.72). CONCLUSION: ICE-guided AF ablation is associated with superior procedural safety and efficiency and a similar risk of AT recurrence compared to non-ICE-guided approaches.