Comparative Outcomes of ICE Versus TEE /Fluoroscopy Guidance Transseptal Puncture in LA Procedures: A Systematic Review and Meta‐Analysis

OBJECTIVE: To evaluate the comparative efficacy, safety, and radiation exposure outcomes of intracardiac echocardiography (ICE)-guided versus TEE/fluoroscopy-guided trans-septal puncture (TSP) in left atrial procedures. METHODS: We conducted a systematic review and meta-analysis of randomized and observational studies comparing ICE-guided with TEE- or fluoroscopy-only-guided TSP. Eight studies encompassing over 9000 patients undergoing atrial fibrillation (AF) ablation or left atrial appendage occlusion (LAAO) were included. Primary endpoints were fluoroscopy time, radiation dose, first-pass success, puncture time, total procedure time, and major safety outcomes. Random-effects models were used to pool mean differences or hazard ratios with 95% confidence intervals (CIs). Risk of bias was assessed using validated tools, and funnel plots with sensitivity analyses evaluated robustness. RESULTS: ICE guidance significantly reduced fluoroscopy time (MD -2.07 min, 95% CI -2.37 to -1.77; p < 0.001) and radiation dose (MD -2.30, 95% CI -3.27 to -1.27; p < 0.001). First-pass success and total procedure time were comparable between groups. Safety endpoints, including tamponade, pericardial effusion, and composite major adverse events, showed no significant increase with ICE. Funnel plots and leave-one-out analyses confirmed the stability of results. CONCLUSION: ICE-guided TSP reduces radiation exposure without compromising efficacy or safety, supporting its adoption as a valuable imaging modality in left atrial interventions.