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Real-time three-dimensional (3D) transesophageal echocardiography (TEE) was used to analyze atrial septal defect (ASD) with 4 goals: (1) to determine feasibility, (2) to analyze the accuracy of qualitative and quantitative data, (3) to assess strengths and weaknesses of the available modes of 3D TEE, and (4) to provide 3D transesophageal echocardiographic reference images.Sixty-five patients with ASDs (age, 5–64 years; weight, 20–114 kg; body surface area, 0.8–2.4 m2) underwent 3D TEE during catheter intervention or surgery. Three-dimensional transesophageal echocardiographic formats included live 3D, 3D zoom, and full-volume 3D modes. Qualitative and quantitative analysis of the 3D data was compared with two-dimensional echocardiographic data and intraoperative inspection.Diagnostic-quality 3D TEE was successfully performed in all 65 patients. Fifty had secundum ASDs and 15 had other ASD types (seven sinus venosus, six primum, one common atrium, and one coronary sinus ASD). ASD type and location were correctly diagnosed in all patients. ASD shape and orientation were confirmed in 21 patients at surgery. Quantitative analysis of ASDs successfully demonstrated rims and changes in dimensions from systole to diastole. Live 3D mode had the highest volume rate, the best transgastric views, and the best views during device deployment but was limited by small sector size. Three-dimensional zoom mode allowed precropped live 3D images but was limited by slow volume rate. Full-volume mode had the best views of large defects and surrounding anatomy. However, it was limited by stitch artifact and required postacquisition cropping.Three-dimensional TEE is feasible and accurate. Each of the 3D transesophageal echocardiographic modalities has strengths and limitations.