“I can see all obstacles in my way. Gone are the dark clouds that had me blind.” Johnny Nash's song about overcoming adversity speaks well to a central challenge in the field of left atrial appendage occlusion (LAAO): seeing clearly the structures and devices necessary to perform the procedure optimally. As procedural volumes increase, attention has shifted toward optimizing procedural efficiency, safety, and resource utilization. Central to this evolution is intraprocedural imaging.

Contemporary multi-society guidelines emphasize that echocardiographic imaging rather than fluoroscopy alone can help minimize complications and ensure complete LAA seal [1]. Transesophageal echocardiography (TEE) combined with fluoroscopy has long been standard for guiding LAAO. This approach provides comprehensive visualization of LAA anatomy, reliable guidance for transseptal puncture, assessment of device sizing, and confirmation of adequate seal. However, TEE typically requires general anesthesia or deep sedation, necessitates a dedicated echocardiographer, and may cause esophageal discomfort or injury, especially in elderly patients. These limitations have prompted increasing interest in alternative, more minimalistic imaging approaches, especially transfemoral intracardiac echocardiography (TF-ICE).