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This narrative review synthesizes contemporary evidence on ICE\u2010guided LAAO. Across observational studies, ICE provides real\u2010time high\u2010resolution imaging enabling accurate trans\u2010septal puncture, device sizing, and deployment under conscious sedation. Procedural success, peri\u2010device leak, and device\u2010related thrombus rates appear comparable between ICE\u2010 and TEE\u2010guided LAAO, while ICE may also shorten fluoroscopy time and avoid general anesthesia. Challenges with ICE include operator learning curve, need for additional venous access and intracardiac catheter manipulation, that may add to risks like pericardial effusions, vascular complications and higher costs. Emerging 3D\/4D ICE and artificial\u2010intelligence\u2013integrated computed tomographic planning may improve efficiency and allow for combined ablation and LAAO procedures. Further randomized controlled trials and cost\u2010effectiveness studies are needed to define the role of ICE\u2010first approach.<\/jats:p>","DOI":"10.1111\/pace.70319","type":"journal-article","created":{"date-parts":[[2026,7,24]],"date-time":"2026-07-24T12:36:13Z","timestamp":1784896573000},"update-policy":"https:\/\/doi.org\/10.1002\/crossmark_policy","source":"Crossref","is-referenced-by-count":0,"title":["Intracardiac Echocardiography\u2013Guided Left Atrial Appendage Occlusion: A Comprehensive Narrative Review"],"prefix":"10.1111","author":[{"ORCID":"https:\/\/orcid.org\/0000-0001-7753-5570","authenticated-orcid":false,"given":"Christian Toquica","family":"Gahona","sequence":"first","affiliation":[{"name":"Cardiology Department Trinity Health Oakland Hospital  Pontiac Michigan USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Roopeessh","family":"Vempati","sequence":"additional","affiliation":[{"name":"Internal Medicine Trinity Health Oakland Hospital  Pontiac Michigan USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Quang Dat","family":"Ha","sequence":"additional","affiliation":[{"name":"Internal Medicine Trinity Health Oakland Hospital  Pontiac Michigan USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Fawaz","family":"Mohammed","sequence":"additional","affiliation":[{"name":"Cardiology Department Trinity Health Oakland Hospital  Pontiac Michigan USA"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0009-0007-7446-2506","authenticated-orcid":false,"given":"Vedanshi","family":"Shah","sequence":"additional","affiliation":[{"name":"Internal Medicine Smt. 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