Intracardiac echocardiography (ICE) has gained increasing use in electrophysiology due to the need to visualize key anatomic structures.  Precise guidance for transseptal puncture and visualization of the pulmonary veins are common essential uses for ICE, but many operators adept at ICE imaging have developed additional and specific uses.  With heavy use of ICE guidance, electrophysiologists demonstrated feasibility of left atrial ablation with minimal use of fluoroscopy.  With the advent of 3D mapping-integrated ICE, rendering of contours for the left atrium, aortic cusps, and left ventricular structures such as the papillary muscles have become possible.  Improved understanding of the anatomy of these areas can facilitate mapping and ablation of these structurally complex sites.  Additional uses of scar-visualization and integration into voltage maps have been explored.  Left atrial appendage imaging has been an area of interest in the ICE community, although technological improvements are likely needed to make this more reliably complete.  A new real-time 3D ICE catheter has also been developed, and work is in progress to delineate potential uses for this new frontier.  Increasingly routine use of ICE has led to improved real-time guidance of all percutaneous cardiac procedures.