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In complex cases (i.e., aorto-right atrial fistula), in order to obtain a complete understating of the clinical picture and possibly recommend appropriate treatments, a thorough investigation is required with attention to technical details that can influence the various calculations and quantifications utilized. Combining all available echocardiographic data—m-mode, 2D, Doppler, 3D—can prove invaluable for understanding the hemodynamics in certain situations. Detailed echocardiographic evaluation can provide important information and be key to making a clinically important diagnosis. Any calculation utilized should be thought of and the information obtained from it should be understood in the larger context, and interpreted accordingly.

Comparing the right-sided cardiac output and left-sided cardiac output is important in situations where a shunt is suspected; it is done by comparing the flow across the LVOT and the RVOT. It is important to remember the limitations and the pitfalls of this technique, as well as to understand precisely the information obtained from these calculations. PDA is a unique example where the classic comparison of the LVOT and RVOT cardiac output results in “confusing” data. Since PDA is an abnormal communication between the right and the left heart occurring outside the heart, it is important to understand which site (LVOT / RVOT) represents which circulation.

Echocardiography can be utilized to assess pulmonary pressures. Pulmonary pressures are an important part of the hemodynamic assessment and carry significant prognostic and therapeutic implications. Most commonly, peak TR velocity is used to estimate pulmonary artery systolic pressure. While this measurement is commonly available and easily obtained, it provides only an estimate of the pulmonary artery systolic pressure, and not mean PA pressure. Mean PA pressure is the parameter used by the WHO to define presence and severity of pulmonary hypertension and carries important diagnostic and prognostic significance. In addition, evaluating pulmonary vascular resistance is critical for the proper classification of pulmonary hypertension and treatment considerations. Echocardiographic techniques are available to further assess pulmonary pressures including pulmonary artery diastolic pressure, mean pulmonary artery pressure, and pulmonary vascular resistance. Like with any other echo obtained measurement, attention to quality and accuracy of the interrogated flow and the obtained spectral signal is of paramount importance in order to assure the accuracy of the obtained data.

Several calculations are utilized in echocardiography to help assess hemodynamic status. Many of these calculations can be carried out at various locations in the heart such that different volumes and pressures can be estimated. In order to understand the clinical significance of the obtained parameters, all available information needs to be taken into consideration. Understanding possible shortcomings of the techniques, impact of technical limitations, and the effects of various cardiovascular pathologies on these parameters is paramount for proper interpretation of the obtained data. The basic parameters and principles that are utilized when assessing hemodynamics by echocardiography include: volume calculations, resistance calculation, Continuity principle, PISA method, and volumetric calculations.

Mitral regurgitation (MR) is one of the most common indications for echocardiography. Accurate quantification of MR severity is extremely important for proper decision-making regarding optimal treatment options. Echocardiography, and frequently trans-esophageal echo, provide thorough quantification information, as well as supporting evidence for the effects of the MR on the heart (e.g., LV/LA enlargement, presence and severity of pulmonary hypertension). It is important to utilize all available tools and measurements when assessing MR severity; reliance on one form of assessment can be deceiving and may result in inaccurate classification of MR severity. Conceptually, the severity of mitral regurgitation is determined by volume—how much blood (in milliliters) spills back from the LV into the LA during systole. A related concept that is also at the crux of determining MR severity is the regurgitant fraction—what percentage of the total stroke volume spills back into the LA. There are multiple echocardiographic quantification techniques for assessing MR severity including anatomic assessment for estimation of regurgitant orifice area, PISA method, color Doppler assessment, and volumetric calculations comparing flow volumes at various locations in the heart. For the most accurate assessment, a comprehensive evaluation should be undertaken and all possible data points should be analyzed.

Intracardiac shunts can occur at various locations and may be the result of a congenital heart defect, other intracardiac pathology (i.e., infectious process), or iatrogenic complications of surgical or structural interventions. When analyzing a ventricular septal defect several parameters must be assessed in order to obtain a comprehensive evaluation. These include type and size of the defect, magnitude and direction of the shunt, cardiac response to the overload (chamber size and function), pulmonary pressures, and pulmonary vascular resistance. Interrogating VSD flow can provide important hemodynamic information and data regarding intracardiac pressures. It is important to make sure that all the flows present are interrogated and measured and obtained parameters should “make sense” when evaluated together; discrepancy in data obtained should prompt a thorough evaluation in order to attain an understanding of the nature of the discordant data.

Mitral regurgitation (MR) is a common valve disease, frequently encountered in echocardiography laboratories. Correct quantification of the severity of the MR is of paramount importance for accurate prognostication and proper treatment planning. The MR spectral Doppler tracing can provide important information regarding intracardiac pressures and be a clue to the presence of various cardiovascular pathologies. Assessing the MR jet velocity is essentially unrelated to the MR severity. Severity is determined by the quantity of the MR—the volume (or fraction) of blood that spills back into the LA instead of being ejected forward through the aortic valve. MR velocity is determined by the pressure gradient driving this velocity, irrespective of the volume of blood that regurgitates back into the LA. Analyzing MR spectral Doppler can provide a clue to the presence of various cardiac (or extra-cardiac) pathologies, and presence of an unusual MR spectral tracing should prompt a search for its cause.

Echocardiography can be utilized to assess pulmonary pressures. Pulmonary pressures are an important part of the hemodynamic assessment and carry significant prognostic and therapeutic implications. The benefits of using echocardiography for assessing pulmonary pressures include the noninvasive nature of the assessment with no known risks, the ability to perform the study at bedside and repeat as needed, and the availability of complementary information (e.g., right ventricular size and function) that can help understand that pathologic process and its impact on the heart. It is essential to understand which pulmonary pressure (e.g., systolic, diastolic, or mean) is measured by each technique in order to have a comprehensive assessment, as well as compare data across various techniques. The most commonly used measurement to assess pulmonary pressure is the interrogation of tricuspid regurgitation jet velocity. This allows for calculation of the pulmonary artery systolic pressure, which provides a good estimate for the presence and severity of pulmonary hypertension.

Timing of events, as well as the pattern of occurrences, are important details to pay attention to. Occasionally, a discrepancy can be found between electrical and mechanical activity of the heart, and echocardiography can be a tool to identify such inconsistency. Moreover, there can be a discrepancy between the mechanical activation of the heart, and the efficiency of the heart (i.e., the production of cardiac output), and echocardiography can play a central role in diagnosing such a situation. Combining information from ECG tracing, 2D and tissue Doppler assessment of contractility, and spectral tracing across the LVOT can provide evaluation of the electrical activation of the heart, mechanical activation of the heart, and the ultimate “success” of these activation efforts in producing cardiac output.

The unusual timing of an otherwise appearing “insignificant” flow can be a clue to various underlying pathologies and should be thoroughly interrogated and investigated. While these abnormal flows may not be clinically important in and of themselves (e.g., may not cause volume overload or increase in filling pressures), understanding the cause of the abnormal timing is important, as it may clarify the underlying pathology. Diastolic mitral regurgitation is an example of such an abnormally timed event; understanding the mechanism and pressure relationships that result in diastolic MR can help shed light on the pathology causing it.

Aortic stenosis (AS) is frequently encountered in echocardiography laboratories. Accurate evaluation of AS severity is essential for proper decisions regarding optimal treatment and timing of interventions. The severity of aortic stenosis is determined by the aortic valve area (at normal flow state), however, multiple criteria are utilized to grade AS severity: calculated aortic valve area, velocity/gradients across the valve, valvuloarterial impedance, valve calcifications, etc. The importance of accurately assessing AS severity and defining the subtype of AS cannot be overstated. It is essential to use meticulous techniques, including imaging from all views and utilizing the non-imaging transduced in order to measure maximal trans-aortic velocities. When discussing trans-aortic gradients it is necessary to specify exactly which gradient is reported—both for understanding the hemodynamic significance of the finding, as well as accurate communication when different techniques are utilized.

Aortic insufficiency (AI) is frequently encountered in echocardiography; regardless of its cause (e.g., valvular, aortic root pathology, etc.), accurate quantification of AI severity is essential for prognostication and treatment planning. Special attention should be paid to parameters that suggest hemodynamically significant AI with increased LV end-diastolic pressure; these may be signs of impending hemodynamic collapse and may necessitate prompt intervention. While often severity and hemodynamic significance go hand in hand, there can be physiologic reasons or technical reasons for the AI to appear less than severe, yet with signs of significant hemodynamic consequences. The importance of identifying these signs cannot be overemphasized; timely intervention may be lifesaving and echocardiographic findings may precede clinical deterioration.

Background Myocardial injury is frequent among patients hospitalized with coronavirus disease-2019 (COVID-19) and is associated with a poor prognosis. However, the mechanisms of myocardial...

Evaluating left ventricular diastolic function and filling pressures is an important consideration in patients presenting with dyspnea or heart failure. Echocardiography has become a key tool for this assessment. This chapter will briefly review the pathophysiology of diastolic dysfunction, the terminology used to describe the stages of diastolic dysfunction and the echocardiographic tools for assessing diastolic function.

This chapter will review the standard transthoracic echocardiographic examination. We will define basic terminology related to standard image acquisition. We will review the views and acquisition technique for the standard views that are obtained on a full TTE. For every view we will describe the structures that can be seen, the relevant chamber quantification (including standard reference values) and important Doppler interrogation that should be performed.

Evaluating cardiac hemodynamics is an important part of interpreting echocardiograms. This chapter will review the principles underlying the non-invasive hemodynamic assessment. We will provide a step by step approach for completing an “echocardiographic Swan-Ganz catheterization” which serves as the building blocks for interrogating complex hemodynamic challenges.

This chapter will provide an overview of the evaluation of left ventricular systolic function by echocardiography. Various parameters of systolic function will be discussed and the different methods of obtaining these will be reviewed. In addition, we will review the basic principles of stress echocardiography and the key concepts in performing and interpreting stress echocardiograms.

Left ventricular outflow tract obstruction is a serious complication of mitral valve surgery (repair and replacement) and transcatheter mitral valve replacement. An appreciation of the various mechanisms which cause outflow obstruction in these settings is critical to avoiding this complication and to initiating appropriate treatment. This article discusses the mechanisms, pathophysiology, and imaging of left ventricular outflow tract obstruction which can arise following insertion of a variety of mitral valve prosthetics.

This chapter provides an overview of the role of three-dimensional echocardiography (3DE) in surgical and percutaneous mitral valve procedures. Throughout the chapter, numerous still images and videos are provided to illustrate the incremental values of 3DE in these procedures. The chapter starts with the description of 3DE imaging of surgical mitral valve replacements and repairs. The 3DE appearance of major types of mechanical and bioprosthetic valves is given including Starr-Edwards, Medtronic Hall, St Jude, and Carpentier Edwards prosthetic valves. Thereafter, an overview of common surgical mitral valve repairs including the Alfieri stitch is discussed. Next, an overview of 3DE in percutaneous alternatives to surgical repairs of native and prosthetic mitral regurgitant lesions is provided including the mitral valve clipping and percutaneous closures of prosthetic paravalvular leaks. The chapter concludes with a description of the role of 3DE in percutaneous mitral balloon valvuloplasty of rheumatic mitral stenosis.

Transcatheter Aortic Valve Replacement (TAVR) effectively treats severe symptomatic aortic stenosis (AS). Left atrial (LA) strain measured by speckle tracking echocardiography quantifies LA function, and has not been evaluated in this population. We measured the baseline reservoir (eR), conduit

Echocardiography plays an important role in the assessment of structural heart disease. The work-up for the assessment for structural interventions often requires a combination of both transthoracic (TTE) and transoesophageal (TEE) imaging. Three-dimensional (3D) echocardiography provides added value to traditional two-dimensional (2D) echocardiography, allowing for definition of anatomical and spatial relationships. Echocardiography is portable and easily accessible, whilst avoiding the need for radiation and contrast making it the preferred mode of imaging in the cardiac catheterisation lab.

AIMS Transcatheter techniques can theoretically be applied to the treatment of para-annular ring (PAR) leaks. Little is known about their potential application and resultant complications in such cases. We describe the first-in-man percutaneous transapical-transseptal Melody valve-in-ring (ViR) implantation after a complication from percutaneous PAR leak closure. METHODS AND RESULTS A 49-year-old woman, at high operative risk, presented with congestive heart failure secondary to severe para-ring/extravalvular regurgitation two months after bypass surgery and mitral ring annuloplasty. Successful percutaneous closure of the leak was performed using an AMPLATZER Vascular Plug IV. One month later, she developed haemolysis with severe PAR regurgitation, through and around the device. After device retrieval and placement of an AMPLATZER Muscular VSD occluder, the patient developed severe intravalvular regurgitation. Completely percutaneous, transseptal delivery of a Melody ViR was performed over a transapical-transseptal, arteriovenous rail. Echocardiography revealed trivial residual regurgitation through the implanted valve with mild transvalvular gradients. CONCLUSIONS Percutaneous closure of mitral PAR leaks after ring annuloplasty in the high-risk patient is feasible (proof-of-concept), particularly when the leak is para-ring/extravalvular. Potential complications include severe intravalvular mitral regurgitation caused by disruption of the mitral apparatus and/or ring deformation during device deployment, which can be successfully treated via percutaneous transapical-transseptal ViR implantation.

Objectives The aim of this proof-of-principle study is to validate the accuracy of fusion imaging for percutaneous transapical access (TA). Background Structural heart disease interventions, including TA, are commonly obtained under fluoroscopic guidance, which lacks important spatial information. Computed tomographic angiography (CTA)-fluoroscopy fusion imaging can provide the 3-dimensional information necessary for improved accuracy in planning and guidance of these interventions. Methods Twenty consecutive patients scheduled for percutaneous left ventricular puncture and device closure using CTA-fluoroscopy fusion guidance were prospectively recruited. The HeartNavigator software (Philips Healthcare, Best, the Netherlands) was used to landmark the left ventricular epicardium for TA (planned puncture site [PPS]). The PPS landmark was compared with the position of the TA closure device on post-procedure CTA (actual puncture site). The distance between the PPS and actual puncture site was calculated from 2 fixed reference points (left main ostium and mitral prosthesis center) in 3 planes (x, y, and z). The distance from the left anterior descending artery at the same z-plane was also assessed. TA-related complications associated with fusion imaging were recorded. Results The median (interquartile range [IQR]) TA distance difference between the PPS and actual puncture site from the referenced left main ostium and mitral prosthesis center was 5.00 mm (IQR: 1.98 to 12.64 mm) and 3.27 mm (IQR: 1.88 to 11.24 mm) in the x-plane, 4.48 mm (IQR: 1.98 to 13.08 mm) and 4.00 mm (IQR: 1.62 to 11.86 mm) in the y-plane, and 5.57 mm (IQR: 3.89 to 13.62 mm) and 4.96 mm (IQR: 1.92 to 11.76 mm) in the z-plane. The mean TA distance to the left anterior descending artery was 15.5 ± 7.8 mm and 22.7 ± 13.7 mm in the x- and y-planes. No TA-related complications were identified, including evidence of coronary artery laceration. Conclusions With the use of CTA-fluoroscopy fusion imaging to guide TA, the actual puncture site can be approximated near the PPS. Moreover, fusion imaging can help maintain an adequate access distance from the left anterior descending artery, thereby, potentially reducing TA-related complications.

An 85-year-old patient presented after an abrupt change in mentation and was found to be hypotensive and hypoxic. Transthoracic echocardiogram (TTE) (see Supplementary data online, Video S1 ) revealed an underfilled, hyperdynamic left ventricle (LV), and a dilated right ventricle (RV) with an akinetic free wall. Pulmonary artery systolic pressure (PASP) was estimated …

Right heart thrombus in the absence of structural heart disease, atrial fibrillation, or intracardiac catheter is rare. It typically represents a thrombus migrating from the venous system to the lung, known as thrombi-in-transit, and can lead to a life-threatening pulmonary embolism. The optimal therapy for thrombi-in-transit remains controversial. We report our experience using percutaneous removal of right heart thrombus using vacuum aspiration.Patients with right atrial mass who were hemodynamically stable and underwent vacuum thombectomy using the AngioVac system (AngioDynamics) at our institution were included in this analysis. Between December 2012 and August 2014, a total of 7 patients (2 men, 5 women) with a mean age of 51.5 years (range, 20-83 years) underwent right atrial thrombectomy. Data during the procedure and follow-up period were collected and analyzed.All patients were hemodynamically stable before the procedure. The procedure was considered successful in 6 patients. All patients survived through hospitalization. No periprocedural bleeding, stroke, or myocardial infarction occurred. One patient developed cardiogenic shock after the procedure that required extracorporeal membrane oxygenation support for24 hours. There was no recurrent venous thromboembolism at a mean follow-up of 9 months.Vacuum-assisted thrombectomy can be a potential treatment option for hemodynamically stable patients with large right-sided intracardiac thrombus who are not surgical candidates.

Assessing left ventricular function is a common indication for echocardiography. It generally requires expert echocardiographer estimation and is somewhat subjective and prone to reader discordance. Mitral annular plane systolic excursion (MAPSE) has been suggested as a surrogate measurement for left ventricular function. The aim of this study was to examine the accuracy of MAPSE for predicting left ventricular ejection fraction (EF) on the basis of a large cohort of consecutive echocardiograms.The study design was a retrospective analysis of 600 two-dimensional echocardiographic studies performed in a single laboratory. MAPSE measurement was performed by an untrained observer and compared with the EF as determined by an expert echocardiographer. The first 300 studies served as a calibration cohort to establish an algorithm for predicting EF on the basis of MAPSE measurement. The following 300 studies served as a verification cohort to test the accuracy of the established algorithm.Using the first 300 studies, an algorithm was developed to predict EF. Cutoff values for normal EF (≥11 mm for women and ≥13 mm for men) and severely reduced EF (6 mm for men and women) were identified. For the intermediate-range MAPSE values, a gender-specific regression equation was calculated to generate a predicted EF. Using this algorithm, predicted EFs were determined for the 300 patients in the verification cohort. By comparing the predicted EF and the expert-reported EF, positive and negative predictive values, sensitivity (73%-92%), specificity (81%-100%), and accuracy (82%-86%) of MAPSE for predicting EF were calculated.MAPSE measurement by an untrained observer was found to be a highly accurate predictor of EF.

Catheter-based mitral valve clip repair (CBMCR) is feasible for selected patients with mitral regurgitation (MR). Two-dimensional (2D) transesophageal echocardiography (TEE) is the standard modality for evaluating MR and procedural guidance. Recently, real-time three-dimensional TEE became available. The aim of this study was to evaluate the value of combined 2D and three-dimensional TEE for CBMCR. In evaluating MR for CBMCR, the confidence of interpretation of 2D TEE was compared with that of combined imaging for the localization of major valve pathology. In patients who underwent CBMCR, the outcomes and the duration of CBMCR were compared.In this retrospective study, MR evaluation was performed by 2D TEE alone and by combined imaging in 80 and 57 patients, respectively. CBMCR was guided by 2D TEE alone in 20 patients and by combined imaging in 39 patients.Examination by combined imaging allowed en face visualization of mitral valve anatomy and MR jet origin. The confidence of interpretation by combined imaging was higher than for 2D TEE (1.1 ± 0.3 vs 1.8 ± 0.7, P.001).The guidance of CBMCR by combined imaging facilitated alignment of the catheter trajectory, clip positioning, and orientation of clip arms. The procedural success and final MR grade were not different between the two study groups. However, the procedural time of CBMCR using combined imaging compared with that using 2D TEE guidance alone was shorter (241 ± 58 vs 201 ± 68 min, P = .035).The use of combined imaging compared with 2D TEE alone appears to enhance the confidence of interpretation concerning mitral pathology and catheter-clip system location and may also reduce CBMCR time.

Background There are currently no standardized three-dimensional (3D) transesophageal echocardiographic (TEE) views of the interatrial septum and atrial septal defects (ASDs). Without a standardized approach, it is difficult to ascertain the important anatomic relationships (such as the location of the aortic rim of an ASD), to perform relevant measurements (such as the size of an ASD or the size of its rims), or to guide the deployment of catheters and devices during atrial septal closure. Methods Using a 3D TEE matrix-array transducer, 706 TEE studies were performed over a 14-month period. The purpose of the study was to develop a standardized protocol for anatomically correct orientation of 3D TEE images of the interatrial septum and ASDs. Results Among 706 TEE studies, there were 23 patients with ASDs, representing 3.3% of the study population. Eighteen patients had secundum ASDs, two had primum ASDs, and three had sinus venosus ASDs of the superior vena cava type. A protocol for properly orienting 3D TEE images of the interatrial septum and ASDs was developed. When the images are acquired at an angle of 0°, the septum is properly oriented by the tilt-up-then-left maneuver. The initial 3D TEE image in first tilted up to reveal the right atrial side of the septum. Then the image is tilted 180° around its vertical axis to reveal the left atrial side of the septum; the aortic rim is on the left, the superior vena cava on the top, and the right-sided pulmonary vein ostia on the right side of the screen. For acquisitions at a higher angle, the rotate-left-in-z-axis maneuver is used. The image is first tilted up to reveal the right atrial side of the septum, as in the tilt-up-then-left maneuver. The image is then rotated counterclockwise in the z axis until the superior vena cave is at 12 o'clock. Finally, the image is tilted 180° around its vertical axis to reveal the left atrial side of the septum. Conclusions The use of standardized tilt-up-then-left and rotate-left-in-z-axis maneuvers enhances the diagnosis of ASDs, ascertains the important anatomic relationships of ASDs to surrounding structures, and facilitates communication between echocardiographers obtaining 3D TEE images and interventional cardiologists or cardiac surgeons performing ASD closures.

Cardiac valve replacement, albeit a well-established and safe procedure, is associated with a significant risk of complications. Symptomatic paravalvular leak (PVL) is a significant post-operative complication of cardiac valve replacement. The prevalence of this complication along with the long-term significance of asymptomatic leaks remains unknown. When these patients develop worsening heart failure or severe haemolysis that requires multiple transfusions from paravalvular regurgitation, the current recommendation is for closure of the leak. The recommended approach has been surgical closure until transcatheter techniques were introduced by Hourihan et al .1 There have been significant innovations in occlusive devices over the past 20 years; however, there are no specifically designed device(s) for the treatment of PVLs. Percutaneous device closure of PVLs has become an attractive alternative to surgical closure. This has further been enhanced by the ability to integrate multi-imaging modalities that have helped to define the pre-operative anatomy as well as to plan and guide the percutaneous closure procedure, resulting in improved outcomes. Since no single imaging modality has the capability to provide all the crucial information that is required for percutaneous closure of PVLs, in our centre we utilize an integrated multiple imaging modalities within a bi-plane cardiac catheterization laboratory. The following modalities assist in the assessment and guidance of percutaneous closure of PVLs. ### Echocardiography Echocardiography is a multifaceted tool used for the diagnosis, quantification, and guidance of treatment of paravalvular prosthetic valve leaks. ### Diagnosis Two-dimensional (2D) echocardiography with spectral and colour Doppler flow images are frequently used for the non-invasive diagnosis of PVLs. Transthoracic echocardiography (TTE) in various imaging planes obtained from the parasternal, apical, subxyphoid, and suprasternal windows helps to define the site of the leak ( Figure 1A ). However, the jet of prosthetic valvular and/or PVL may be overshadowed by the prosthetic valve, thus underestimating the degree of leak …

We review the use of real-time three-dimensional transesophageal echocardiography (RT3D-TEE) in guiding percutaneous catheter-based procedures to repair structural heart defects. The utility of this novel imaging technique in percutaneous mitral valve repair and valvuloplasty, aortic valve insertion, device closure of atrial and ventricular septal defects, obliteration of the left atrial appendage, and pulmonary vein ablation is described. The main advantages of RT3D-TEE lie in its ability to visualize the entire length of intracardiac devices, including their tips, and to demonstrate their relationship to cardiac structures, to provide en face views of cardiac structures (such as the interatrial septum and the mitral valve) that are unobtainable in real time by any other imaging technique, and to allow for continuous monitoring during the procedure. It is likely that RT3D-TEE will become the standard of care for guidance of percutaneous, catheter-based procedures.

Background Real-time three-dimensional (RT3D) echocardiography is a recently developed technique that is being increasingly used in echocardiography laboratories. Over the past several years, improvements in transducer technologies have allowed development of a full matrix-array transducer that allows acquisition of pyramidal-shaped data sets. These data sets can be processed online and offline to allow accurate evaluation of cardiac structures, volumes, and mass. More recently, a transesophageal transducer with RT3D capabilities has been developed. This allows acquisition of high-quality RT3D images on transesophageal echocardiography (TEE). Percutaneous catheter-based procedures have gained growing acceptance in the cardiac procedural armamentarium. Advances in technology and technical skills allow increasingly complex procedures to be performed using a catheter-based approach, thus obviating the need for open-heart surgery. Methods The authors used RT3D TEE to guide 72 catheter-based cardiac interventions. The procedures included the occlusion of atrial septal defects or patent foramen ovales (n = 25), percutaneous mitral valve repair (e-valve clipping; n=3), mitral balloon valvuloplasty for mitral stenosis (n = 10), left atrial appendage obliteration (n = 11), left atrial or pulmonary vein ablation for atrial fibrillation (n = 5), percutaneous closures of prosthetic valve dehiscence (n = 10), percutaneous aortic valve replacement (n = 6), and percutaneous closures of ventricular septal defects (n = 2). In this review, the authors describe their experience with this technique, the added value over multiplanar two-dimensional TEE, and the pitfalls that were encountered. Results The main advantages found for the use RT3D TEE during catheter-based interventions were (1) the ability to visualize the entire lengths of intracardiac catheters, including the tips of all catheters and the balloons or devices they carry, along with a clear depiction of their positions in relation to other cardiac structures, and (2) the ability to ability to demonstrate certain structures in an "en face" view, which is not offered by any other currently available real-time imaging technique, enabling appreciation of the exact nature of the lesion that is undergoing intervention. Conclusion RT3D TEE is a powerful new imaging tool that may become the technique of choice and the standard of care for guidance of selected percutaneous catheter-based procedures.