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Radiation reduction is desirable in children undergoing cardiac catheterization. Three-dimensional (3D) transesophageal echocardiographic (3D TEE) imaging obviates the need for mental reconstruction of 3D structures from two-dimensional images. Three-dimensional TEE imaging is used in atrial septal defect (ASD) closures. Three-dimensional TEE guidance of right heart catheterization (RHC) without fluoroscopy for ASD closures has not been demonstrated. The aim of this study was to evaluate the feasibility of 3D TEE guidance of RHC in ASD closures and radiation reduction compared with historical control subjects.Twenty-two patients underwent 3D TEE guidance of RHC and ASD closures and were compared with 44 control subjects. RHC time, total fluoroscopy time, radiation dose, and procedural time were compared. Fluoroscopy time during RHC was recorded in patients undergoing 3D TEE guidance.There was a 54% reduction in total fluoroscopy time and a 78% radiation reduction demonstrated with 3D TEE guidance of patients with ASDs compared with control subjects. Although there were no statistically significant differences in the RHC time compared with control subjects, the fluoroscopy time (mean, 0.06 ± 0.23 min) for RHC guidance using 3D TEE imaging was almost zero. There was decreased RHC time as we progressed through the learning curve of performing 3D TEE guidance of RHC (r = −0.63, P < .01). There were no statistically significant differences in total procedural time.Three-dimensional TEE guidance in RHC is feasible without the use of fluoroscopy and reduces radiation exposure in percutaneous ASD closures. Three-dimensional TEE guidance may be used in other interventional procedures in the future to further reduce radiation exposure and facilitate catheter interventions.Radiation dose reduction is desirable in patients undergoing cardiac catheterization.3D TEE guidance decreases radiation exposure for percutaneous ASD closures.There is a learning curve for 3D TEE imaging to guide right heart catheterization.At present, TEE probe size is limited to patients weighing >16 kg.