Left atrial appendage occlusion (LAAO) has emerged as an important therapy for patients with atrial fibrillation at risk for stroke who are not good candidates for long-term oral anticoagulation. Transesophageal echocardiography (TEE) has an important and foundational role in preprocedural left atrial appendage assessment, intraprocedural guidance and device deployment, and post-procedural evaluation in follow-up. Recent studies have evaluated intracardiac echocardiography (ICE) as a primary intraprocedural imaging modality without the need for TEE. The use of ICE offers promise of expedited patient care, reduced procedural complexity, and reduced costs. Observational reports of ICE for LAAO highlight significant variability in procedural technique, including but not limited to ICE catheter placement and position as well as the type and number of intracardiac views. Integration with concomitant electroanatomic mapping provides additional information to the operator regarding the orientation of the ICE catheter to the atrial geometry and can be used to optimize views and avoid perforation. It also allows for more precise near-field delineation of transseptal access. This review characterizes a standardized approach for harnessing ICE based off four anatomic views (aortic, mitral, left superior pulmonary vein, and inferior). These views optimize the unique vantage points of left atrial ICE as opposed to attempting to replicate the transesophageal windows. The focus on complementary and orthogonal angles allows for more precise device placement and assessment for device positioning and peri-device leak.
