- Aims Currently, two-dimensional transesophageal echocardiography (2DTEE) at a cut-plane angulation of 135° is the recommended method to size maximal left atrial appendage (LAA) orifice diameter before introducing a percutaneous LAA closure device. We compared real time three-dimensional TEE (RT3DTEE) and 2DTEE for measuring LAA dimensions versus computed tomography (CT) as gold standard. Methods and Results We prospectively studied 30 consecutive patients who underwent a routine TEE examination, using QLAB 10.0 Application on EPIQ7 iE33 3D echo machine between December 2012 and December 2013. All patients underwent 64-slice CT before pulmonary vein isolation or for workup of pulmonary embolism. LAA measurements were compared between 135 2DTEE and RT3DTEE. Results were compared with CT measurements. Using RT3DTEE, larger LAA diameters were measured versus 2DTEE (23.5 ± 3.9 vs. 24.5 ± 4.7 mm). In seven patients (23.3%), the measurements in 135° 2DTEE were smaller than the cut-plane angulation with maximal orifice diameter. RT3DTEE measurements of LAA were not different from CT regarding number of lobes, area of orifice, and maximal diameter. LAA volume could not be measured directly using RT3DTEE. No difference was found between LAA depth using RT3DTEE (19.5 ± 2.3 mm) vs. CT (19.6 ± 2.3, P = NS) and 2DTEE (19.4 ± 2.2 mm) vs. CT (P = NS). However, RT3DTEE (24.5 ± 4.7 mm) vs. CT (24.6 ± 5, P = NS) was more accurate in measuring maximal LAA diameter compared to 2DTEE (23.5 ± 3.9 mm) vs. CT (P < 0.01). Conclusion RT3DTEE method is more accurate than 2DTEE for assessment of maximal LAA orifice diameter. Bedsides, RT3DTEE LAA measurements are not statistically different from CT. Thus, RT3DTEE may facilitate LAA closure procedure by choosing the appropriate device size.