Long-term outcomes of ICE-guided left atrial appendage occlusion from a large single-center experience

Background: Intraprocedural imaging is pivotal for guidance of left atrial appendage closure (LAAC) to minimize complications and ensure optimal sealing. Intracardiac echocardiography (ICE) has emerged as a less invasive alternative to transesophageal echocardiography (TEE), although long-term outcome data remain limited. Objectives: To evaluate procedural success and long-term clinical outcomes of ICE-guided LAAC in a large single-center cohort. Methods: Consecutive patients undergoing ICE-guided LAAC (January 2009–March 2024) were analyzed. Kaplan–Meier and Cox regression assessed time-to-event outcomes and mortality predictors; supplementary Aalen-Johansen competing-risk analyses derived cumulative incidence functions (CIF) for non-fatal endpoints, with all-cause mortality as the competing event. Results: Among 411 patients, technical and procedural success were 99.8% and 94.9%, respectively. Major adverse events occurred in 5.1%, mainly pericardial tamponade (2.9%); no in-hospital deaths. Over a mean follow-up of 44.2months, all-cause mortality was 45.3% (annualized rate 10.9%). Twenty-one ischemic events occurred (annualized rate 1.7%), yielding an observed-to-expected ratio of 0.27 (95%CI: 0.17–0.41) versus the CHA₂DS₂-VASc-predicted burden (73% relative reduction). Major bleeding occurred in 3.2% (annualized rate 1.1%). Five-year CIF estimates were 5.12% for stroke/TIA and 2.65% for major bleeding (ISTH). Advancing age, renal insufficiency, diabetes mellitus, and reduced LVEF independently predicted all-cause mortality. Conclusions: ICE-guided LAAC is safe and highly effective, with favorable long-term outcomes and low ischemic and bleeding event rates in a high-risk population.