Prof. Petr Peichl, Institute for Clinical and Experimental Medicine (IKEM), Prague, Czechia
What is the reason for and aim of the publication?
Intracardiac echocardiography (ICE) is an imaging technique that provides real-time, detailed visualization of intracardiac structures during various interventional procedures performed in the electrophysiology (EP) laboratory. The aim of the paper is to provide a practical framework for the use of ICE, offering a systematic guide to its applications, benefits, and implementation in daily clinical practice. The document covers fundamental principles of ICE imaging, standardised views, its role in transseptal puncture, ablation of supraventricular and ventricular arrhythmias, reduction of procedural radiation, early detection and management of periprocedural complications, identification of infective endocarditis, and guidance during endomyocardial biopsy and left atrial appendage occlusion procedures.
What are the most important take-home messages?
Multiple observation trials have shown that routine use of ICE significantly improves procedural safety and precision by enabling real-time visualization of cardiac anatomy, catheter positioning, and early detection of complications. It also allows substantial reduction or elimination of fluoroscopy and contrast use, supporting safer workflows. Finally, ICE is evolving into an integrated imaging platform through its combination with electroanatomical mapping and emerging AI-based tools, enhancing procedural efficiency and reproducibility.
What are challenges in practical implementation – and possible solutions?
Implementation of ICE is limited by a significant learning curve and relatively high costs of disposables, which leads to disparities in use of ICE within the EU region. These challenges may be addressed through structured training, standardization of workflows, selective use only in complex cases, and further clinical research to strengthen the evidence base and clarify cost-effectiveness. In some EU countries reprocessing of the disposables is allowed, which greatly decreases the costs.
Which issues still need to be tackled, that are not yet addressed by the paper?
Key unresolved issues are the lack of randomized controlled trials, and insufficient data on cost-effectiveness and reimbursement. Furthermore, emerging technologies such as AI-based reconstruction require broader validation.
What further developments on the topic are emerging?
Emerging developments include the expansion of 3D and 4D ICE imaging, integration with electroanatomical mapping systems, and the use of artificial intelligence for automated anatomical reconstruction. There is also a growing shift toward fluoroless procedures and broader application of ICE in structural heart interventions, suggesting an expanding role in interventional cardiology.
Intracardiac echocardiography during invasive electrophysiological procedures
Peichl P, et al. Intracardiac echocardiography during invasive electrophysiological procedures. A scientific statement of the European Heart Rhythm Association of the ESC, and the European Association of Percutaneous Cardiovascular Interventions of the ESC. Europace. Published online April 13, 2026. doi:10.1093/europace/euag059
Document types published by the ESC, Associations, Councils, Working Groups, and ESC Committees (according to the ESC Scientific Documents Policy):
