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Transcatheter left atrial appendage (LAA) occlusion is emerging as a potential alternative to anticoagulation therapy for the prevention of cerebrovascular events in those patients with permanent or paroxysmal atrial fibrillation (AF). The aim of our study is to evaluate the role of 3D real time tranesophageal echocardiography (3DRT TEE) in this procedure when using a new device, the Amplatzer Cardiac Plug (ACP).Methods: data from 37 patients (p) submitted to our clinic for percutaneous LAA occlusion were collected from December 2008 to March 2011. All the patients had paroxysmal or permanent AF with an elevated cardio-embolic score (CHA2DS2VASc ≥ 2) and a major contraindication to oral anticoagulant therapy. A 3DRT TE was performed in all p before the procedure in order to evaluate the anatomy and dimensions of LAA and the exclude the presence of thrombosis. Each procedure was monitored usimng TE. After the procedure patients were submitted to 3DRT TE to evaluate the correct position of the device. Patients were treated with dual antiplatelet therapy for 4 weeks.Results: Mean age was 77 years. 62% of patients were male. After the preprocedural evaluation 2 patients were excluded because of the presence of LAA thrombosis; moreover LAA anatomy was judged not suitable for the procedure in one p. LAA occlusion was performed in 34 p using TE monitoring. The ACP was successfully implanted in 33 of 34 patients. No acute complications were observed. At follow-up 4 patients were dead for non procedural related causes (two pulmonary embolism, one cancer, one congestive heart failure). None of the patients implanted had a TIA or stroke during the follow up period. TE was performed in 29 patients at a mean time of 11 months (range 2-18) after the procedure, demonstrating no malposition nor embolization of the device, neither left atrial thrombosis. In one case there was a small residual shunt in LAA. Mitral valve movement, transmitral flow and left superior pulmonary vein were not affected by the presence of the device.Conclusions: 3DRT TEE is a very useful technique in the pre-procedural evaluation, monitoring and follow-up examination of p who are candidates for percutaneous LAA occlusion with ACP. This technique contributes to study the complex anatomy of LAA and to evaluate dimensions and morphology of its ostium; moreover, it contributes to make the procedure safe and to increase the procedural success rate.