OBJECTIVE:A simplified mitral valve transcatheter edge-to-edge repair workflow under sole transesophageal echocardiographic guidance, without fluoroscopy, has been developed. This study aimed to compare its real-world outcomes with the conventional procedures under the combined guidance of fluoroscopy and transesophageal echocardiography. METHODS:We retrospectively analyzed 386 patients undergoing mitral valve transcatheter edge-to-edge repair between January 2021 and December 2025, including 286 in the sole transesophageal echocardiography guidance group and 100 in the combined guidance group. The primary end points were cardiovascular mortality, all-cause mortality, and a composite of all-cause mortality and heart failure hospitalization. Propensity score matching and overlap weighting were performed as sensitivity analyses. RESULTS:Technical success was achieved in 98.3% and 97.0% of patients in the sole transesophageal echocardiography group and combined guidance group, respectively, and 30-day major adverse events occurred in 2.8% and 7.0%, respectively (P > .05). The median follow-up was 16.5 months. At 1 year, the estimated cumulative incidence rates of the 3 primary end points were 4.4%, 6.0%, and 11.3% in the sole transesophageal echocardiography guidance group and 6.4%, 8.5%, and 11.3% in the combined guidance group, respectively (P > .05). Mitral valve transcatheter edge-to-edge repair failure at 1 year was 4.8% and 6.3%, respectively (P > .05). The corresponding adjusted hazard ratios (95% CIs) for the 3 primary end points were 1.52 (0.61-3.79), 0.96 (0.42-2.18), and 0.93 (0.48-1.81), respectively. Findings were consistent in sensitivity and subgroup analyses. CONCLUSIONS:In this real-world observational cohort, mitral valve transcatheter edge-to-edge repair performed under sole transesophageal echocardiography guidance was associated with favorable procedural and follow-up outcomes, supporting the feasibility of this simplified workflow in experienced centers.

OBJECTIVES:This study aims to compare intraoperative blood transfusion and perioperative outcomes for patients undergoing left ventricular assist device (LVAD) implantation before and after the implementation of a blood conservation protocol. METHODS:This retrospective cohort study included patients who underwent LVAD implantation from June 2017 to October 2024 at our Hospital. The primary outcome was total intraoperative transfusion volume, and secondary outcomes included intraoperative transfusion volume and rates of red blood cells (RBC), fresh frozen plasma (FFP), platelets, and reoperation due to bleeding. Exploratory outcomes included mortality and serious complications before hospital discharge. RESULTS:In total, 120 patients were included, with 62 receiving traditional care and 58 treated with blood conservation protocol. After protocol implementation, total intraoperative transfusion volume decreased from 3.23 ± 3.24 units to 1.74 ± 1.56 units (P = 0.002). The intraoperative RBC transfusion rate dropped from 30.6% to 8.6% (P = 0.003), and the transfusion volume fell from 1.00 ± 1.71 units to 0.31 ± 1.05 units (P = 0.009). In multivariate analysis, the protocol was significantly associated with reduced total intraoperative transfusion volume, lower RBC transfusion volume and rate, and shorter ICU and hospital stays, while not correlated with perioperative mortality or serious complications. CONCLUSIONS:The blood conservation protocol significantly reduced intraoperative transfusion in LVAD patients and expedited recovery.

BACKGROUND:Transcatheter edge-to-edge mitral valve repair is a key therapeutic option for patients with severe symptomatic mitral regurgitation at high surgical risk. This prospective study aimed to develop a novel end-to-end deep learning model for preoperative artificial intelligence assessment in transcatheter edge-to-edge mitral valve repair (TEERAI-pre) candidates using multiview, multimodal echocardiography. METHODS:TEERAI-pre, a video vision transformer-based classification model, predicts morphological suitability for transcatheter edge-to-edge mitral valve repair from multiview, multimodal echocardiography. A transformer-based feature-level fusion module was designed in TEERAI-pre to integrate multiview, multimodal features for final prediction. An internal data set of 633 patients (7997 transthoracic echocardiographic videos; 766 pulsed-wave Doppler images) was split for 5-fold cross-validation. An external data set of 150 patients (1735 transthoracic echocardiographic videos; 169 pulsed-wave Doppler images) across 2 hospitals evaluated generalizability. Reference standards were provided by 2 experienced valvular cardiologists per international guidelines. RESULTS:On the internal data set, TEERAI-pre achieved 75.0% accuracy (95% CI, 71.7%-78.4%) for classifying red (unsuitable), yellow (challenging), and green (ideal) zones, with 77.1% precision, 75.5% recall, and 76.2% F1 score. External validation yielded 73.3% accuracy, 74.0% precision, and 74.0% recall. Multiview multimodal integration improved performance. Binary classification (red versus green) showed TEERAI-pre matched senior experts and outperformed intermediate/junior echocardiologists. Feature-level fusion outperformed output-level fusion and single-view model. Backbone selection and calibration analysis confirmed robust performance. CONCLUSIONS:TEERAI-pre demonstrates strong performance in transcatheter edge-to-edge mitral valve repair preoperative assessment using transthoracic echocardiographic videos and images, supporting more accurate patient selection and enhancing clinical workflow efficiency. REGISTRATION:URL: clinicaltrials.gov; Unique Identifier: NCT05508438.

Background:Valve-sparing root replacement (VSRR) prevents prosthesis-related complications in aortic root aneurysms but lacks objective feasibility criteria. Cusp prolapse frequently coexists with aortic root aneurysms, but its effect on VSRR outcomes remains unclear. We characterized prolapse mechanisms using three-dimensional (3D) transesophageal echocardiography (TEE) and examined the correlation between imaging features and surgical success as well as midterm outcomes. Methods:This retrospective cohort study analyzed the data of 203 consecutive patients considered for VSRR. Cusp prolapse was diagnosed and mechanistically classified using quantitative 3D TEE analysis. The intraoperative findings confirmed regurgitation mechanisms. The outcomes compared the native valve preservation rates, postoperative echocardiographic results, mortality, regurgitation recurrence, and reintervention between prolapse and non-prolapse groups over a median 41-month follow-up period. Results:Among the 203 patients (mean age 48.0±13.7 years), 70 (34.5%) exhibited cusp prolapse. The predominant mechanism was disproportionate free margin (FM) elongation (64.3%). Surgical success was significantly lower in the prolapse group than the non-prolapse group (50.0% vs. 86.5%; P<0.001). Among the patients with cusp prolapse, prolapse mechanisms other than FM elongation, compared with FM elongation, were independently associated with unsuccessful VSRR [odds ratio (OR) =12.44; 95% confidence interval (CI): 3.42-45.24; P<0.001]. In addition, a reduced minimum geometric height was also independently associated with unsuccessful VSRR (OR =0.70; 95% CI: 0.50-0.97; P=0.035). There were no significant differences in the midterm outcomes between the prolapse and non-prolapse groups in terms of the echocardiographic parameters (P=0.373), mortality (P=0.581), regurgitation recurrence (P=0.769), or reintervention rates (P=0.580). Conclusions:Cusp prolapse-driven by heterogeneous mechanisms-is prevalent in tricuspid aortic valve root aneurysms and reduces the likelihood of successful VSRR. Preoperative 3D TEE quantification of cusp pathology can aid in surgical planning. Despite lower preservation rates in prolapse patients, both groups achieved comparable midterm outcomes following judicious patient selection.

BACKGROUND:Leadless pacemaker implantation traditionally relies on fluoroscopy and contrast-guided techniques. However, in patients with advanced chronic kidney disease, the use of contrast carries a risk of nephrotoxicity, and fluoroscopy leads to additional ionizing radiation exposure. CASE SUMMARY:We report a case of a 69-year-old man with occasional sinus arrest and end-stage renal disease on hemodialysis who successfully underwent implantation of an Aveir VR leadless pacemaker (Abbott, USA) entirely under transthoracic echocardiographic (TTE) guidance, without fluoroscopy or contrast. Using a Philips EPIQ system with an X5-1 transducer, key procedural steps-including navigation, septal positioning, pacing threshold testing, and final deployment-were completed under real-time ultrasound visualization. Post-procedural pacing parameters were optimal, and no complications occurred. Chest radiography confirmed appropriate device position. CONCLUSION:This case demonstrates the potential feasibility and safety of an ultrasound-guided implantation technique for the Aveir VR leadless pacemaker. It may offer a promising alternative for patients with contraindications to radiation or contrast agents. Larger studies are needed to validate and standardize this approach.

Quadricuspid pulmonary valve (QPV) is a rare congenital anomaly with limited reports. This study characterizes QPV morphology and function by multimodal imaging, evaluates predictors of moderate-to-severe pulmonary regurgitation (PR), and assesses mid-term prognosis. Retrospective search of the imaging database at a tertiary medical center identified patients diagnosed with QPV between October 2004 and September 2024. Multimodal imaging was utilized to assess the characteristics of QPV and associated abnormalities. Among 1,367,280 cardiac CT and MR exams, 16 patients were diagnosed with QPV (38

Transradial access (TRA) is the standard vascular approach for coronary interventions because it lowers bleeding risk and improves patient comfort. Nevertheless, radial artery occlusion (RAO) remains an important limitation, preventing re-use of the radial artery for subsequent procedures. Distal transradial access (dTRA) has been proposed as a strategy to further reduce RAO while preserving procedural efficacy. To assess whether dTRA reduces early and mid-term RAO compared with conventional TRA in patients undergoing percutaneous coronary intervention (PCI). In this single-center, prospective, randomized, open-label superiority trial, 426 consecutive patients scheduled for elective PCI between July 2023 and January 2024 were assigned 1:1 to dTRA (n = 213) or TRA (n = 213). Duplex ultrasonography was used to assess RAO at 24 h and 30 days. Primary endpoint: 24-hour RAO; secondary endpoints: 30-day RAO, procedural success, hemostasis time, radiation exposure, and hand/wrist function scores. One patient withdrew consent, leaving 425 patients (dTRA 213, TRA 212) for analysis. The 24-hour RAO rate was significantly lower in the dTRA group compared to the TRA group (0.5

Early right heart failure (RHF) after left ventricular assist device (LVAD) implantation poses significant morbidity and mortality risks. Existing RHF prediction scores are complex, typically requiring multiple indicators and evaluation steps. This research aimed to explore a more feasible predictor for initial screening of early RHF. This multicenter, retrospective analysis included 83 consecutively enrolled patients undergoing continuous-flow LVAD implantation. Multivariable logistic regression identified independent predictors of early RHF, whereas receiver operating characteristic (ROC) curve analysis assessed predictive value. Among the 83 patients, 21 (25.3%) experienced early RHF. Logistic regression analyses revealed that the direct bilirubin to total bilirubin (DBIL/TBIL) ratio on admission was significantly correlated with early RHF (adjusted odds ratio [OR]: 2.41, 95% confidence interval [CI]: 1.35-4.31, p = 0.003). The DBIL/TBIL ratio on admission exhibited the highest area under the receiver operating characteristic curve (AUC) (0.767, 95% CI: 0.661-0.852). Internal validation using bootstrap techniques resulted in a mean AUC of 0.767 (95% CI: 0.640-0.879), whereas external validation in a cohort of 31 patients demonstrated an AUC of 0.682 (95% CI: 0.491-0.837). An optimal DBIL/TBIL ratio threshold of 0.52 yielded 76.19% sensitivity and 79.03% specificity for early RHF prediction. In subgroups with different TBIL levels, sensitivity and specificity were 70.0% and 86.67% for TBIL greater than or equal to 2 mg/dl, and 81.82% and 76.60% for TBIL less than 2 mg/dl, respectively. The DBIL/TBIL ratio upon admission is a viable predictor of early RHF following LVAD implantation, demonstrating acceptable predictive efficacy.

Distal radial artery access (dTRA) reduces radial artery occlusion (RAO) and improves safety compared with conventional transradial access, yet its use in complex coronary interventions necessitating larger guiding catheters remains limited. Thin-walled 7F sheaths with reduced external diameter may overcome this barrier. We present the protocol for a multicentre, randomized, open-label, noninferiority trial enrolling 574 patients aged 18 to 80 years with distal radial artery diameter ≥ 1.7 mm who are scheduled for elective percutaneous coronary intervention (PCI) across 5 Chinese centres. Participants are centrally randomized 1:1 to receive either a 7F thin-walled sheath (experimental) or a 6F thin-walled sheath (control) via dTRA. The primary endpoint is RAO and distal RAO at 24 hours, evaluated by Doppler ultrasound. Secondary endpoints include cannulation and procedural success, crossover to alternative access, RAO and distal RAO at 30 days, hematoma (EASY scale), major bleeding (BARC), pain (VAS), functional status (Barthel Index), length of stay, and total hospitalization costs. Data are collected pre-, intra-, and postprocedure, with follow-up at 24 hours and 30 days. Results will provide robust evidence on the safety and efficacy of 7F thin-walled sheaths in dTRA for complex PCI, informing optimal equipment selection and procedural strategies. CLINICAL TRIAL REGISTRATION: NCT06585917.

BACKGROUND:Transcatheter edge-to-edge repair (TEER) is widely used for high-risk degenerative mitral regurgitation (DMR), but the range of leaflet lesions that can be managed with one single clip remains unclear. This study aimed to evaluate the range of leaflet lesions treatable with one clip during TEER in DMR patients. METHODS:We retrospectively analyzed intraoperative echocardiograms from 106 DMR patients undergoing TEER. Logistic regression was used to identify anatomical factors affecting satisfactory results after the first clip. Optimal cut-off values were determined using Receiver-operator characteristics (ROC) curve analysis and subsequently validated with follow-up data. RESULTS:Forty-three patients achieved satisfactory result after the first clip. Multivariate analysis identified prolapse width (p < 0.001) and prolapse gap (p = 0.039) as independent predictors for satisfactory result after the first clip. ROC analysis showed superior predictive value for prolapse width (AUC = 0.877 vs. 0.734). The optimal prolapse width cut-off value was 14 mm when the Youden index reached maximum value of 0.699 (sensitivity 0.746, specificity 0.953). Patients with width > 14 mm had significantly higher adverse event rates (Log-rank, Breslow, Tarone-Ware p = 0.007, 0.007, 0.006). Consistent results were also obtained in the subgroup of patients finished TEER with 1 clip (Log-rank, Breslow, Tarone-Ware p = 0.065, 0.030, 0.038). CONCLUSIONS:Prolapse width is a key independent predictor of outcomes after the first clip implantation in TEER procedure. The incidence of postoperative severe adverse events is higher in patients with a prolapse width exceeding 14 mm, regardless of the number of clips implanted.

Background:Diagnosis of left ventricular outflow tract (LVOT) obstruction in hypertrophic cardiomyopathy (HCM) by echocardiography requires specific provocation tests. We aimed to explore the echocardiographic parameters (under resting conditions) associated with latent obstruction in patients with HCM. Methods:Echocardiographic data of 138 patients (65 with resting obstruction, 38 with latent obstruction, and 35 without obstruction) with HCM were analyzed. Under the resting condition, parameters of basal septal morphology [IVSa (area of basal septum protruding into the LVOT), LA (depth of IVSa relative to the LVOT), LB (length of IVSa in the direction of the left ventricular long axis), and S-IVSa (IVSa divided by LB)], the angle between the mitral valvular orifice and ascending aorta (MV-AO angle), and routine echocardiographic parameters were measured and compared among the three groups. Further analyses were conducted on patients with and without latent LVOT obstruction. Associations between parameters and latent obstruction were assessed using multivariate logistic regression analysis and receiver operating characteristic (ROC) curves. Results:The MV-AO angle, LA, S-IVSa, length of the posterior mitral leaflet, and presence of abnormal muscle bundles (MBs) were significantly different between patients with and without latent obstruction (P<0.001, P=0.006, P=0.016, and P=0.001, respectively). In multivariate analyses, the MV-AO angle, presence of abnormal MBs, and S-IVSa were independently associated with latent obstruction (P<0.001, P=0.013, and P=0.022, respectively). The ROC curves of the model consisting of these parameters showed a stronger association with latent obstruction; the area under the ROC curve was 0.954 [95% confidence interval (CI): 0.878-0.989]. Conclusions:Combining S-IVSa with the MV-AO angle and abnormal MBs evaluated at rest can effectively identify patients with provocable obstruction, making the new model a valuable tool for improving the detection rate of latent obstruction and benefiting more patients.

Background Data on mitral valve transcatheter edge-to-edge repair (M-TEER) in Asian patients are limited. This study evaluates the anatomical suitability and clinical efficacy of M-TEER in Chinese patients with moderate-to-severe or severe mitral regurgitation (MR). Methods This study included symptomatic patients with moderate-to-severe or severe MR who underwent M-TEER echocardiographic screening at Fuwai Hospital from January 2021 to February 2024. Patients were classified according to current anatomical criteria for M-TEER. Clinical characteristics, echocardiographic parameters, and treatments were summarized, focusing on the procedural success of M-TEER and 1-year MR recurrence rates. Results A total of 481 patients were enrolled, including 304 with degenerative MR (DMR) and 150 with functional MR (FMR). The average age was 68.81 years, 44.28 % were female, and 70.69 % had severe MR. DMR patients had smaller absolute left atrial and ventricular diameters compared to FMR patients. Ideal, suitable, challenging, and impossible M-TEER anatomy was found in 23.49 %, 36.17 %, 13.93 %, and 26.4 % of patients, respectively. Among those who underwent M-TEER, these proportions were 36 %, 46 %, 15 %, and 3 %. The 1-year cumulative incidence of MR recurrence was similar between different etiologies but significantly lower in patients with ideal/suitable anatomy compared to those with challenging/impossible anatomy (5.28 % vs 11.86 %, P = 0.003). Multivariable analysis showed that a leaflet-to-annulus index <1.2 was associated with approximately a 5.8-fold increased risk of MR recurrence within one year. Conclusion Among patients with significant MR, 59.66 % had ideal/suitable M-TEER anatomy, but only 48 % received treatment, indicating potential undertreatment. Patients with ideal/feasible anatomy had higher procedural success rates and lower recurrence risks.

BACKGROUND To develop a novel complexity evaluation system for mitral valve repair based on preoperative echo- cardiographic data and multiple machine learning algorithms. METHODS From March 2021 to March 2023, 231 consecutive patients underwent mitral valve repair. Clinical and echocardiographic data were included in the analysis. The end points included immediate mitral valve repair failure (mitral replacement secondary to mitral repair failure) and recurrence regurgitation (moderate or greater mitral regurgitation [MR] before discharge). Various machine learning algorithms were used to establish the complexity evaluation system. RESULTS A total of 231 patients were included in this study; the median ejection fraction was 66% (63-70%), and 159 (68.8%) patients were men. Mitral repair was successful in 90.9% (210 of 231) of patients. The linear support vector classification model has the best prediction results in training and test cohorts and the variables of age, A2 lesions, leaflet height, MR grades, and so on were risk factors for failure of mitral valve repair. CONCLUSION The linear support vector classification prediction model may allow the evaluation of the complexity of mitral valve repair. Age, A2 lesions, leaflet height, MR grades, and so on may be associated with mitral repair failure. (Hellenic Journal of Cardiology 2025;81:25-37) (c) 2024 Hellenic Society of Cardiology. Publishing services by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/).

Double-orifice mitral valve (DOMV), a rare congenital heart disease, is the inspiration behind the transcatheter edge-to-edge repair (TEER). Here we report a successful TEER case in a patient with DOMV with severe regurgitation. The patient’s symptoms were greatly improved after the procedure.

BACKGROUND:Left ventricular assist devices (LVADs) are well-established for treating end-stage heart failure, but this therapy is only available to Chinese patients in recent years. The CH-VAD is the first used fully magnetically levitated pump in China. This study reports the long-term outcomes of a cohort supported by the CH-VAD for the first time. METHODS:From June 2017 to August 2023, 50 consecutive patients received CH-VAD implantation in Fuwai Hospital. Clinical data were collected and retrospectively analyzed. RESULTS:Baseline characteristics included a mean age of 47.9 ± 13.9 years, 90% male, and 26% ischemic etiology. The Interagency Registry for Mechanically Assisted Circulatory Support profile revealed 12% profile 1, 56% profile 2, 26% profile 3, and 6% profile 4. The mean support duration was 868 ± 630 days (range 33 days-6.4 years). Kaplan-Meier survival rate was 93% (95% CI, 79-98) at 1 year, 93% (95% CI, 79-98) at 2 years, and 89% (95% CI, 71-96) at 3 years. Forty patients (80%) currently remain on support, 3 were bridged to recovery, 2 received transplants, and 5 expired during support. Major adverse events (AEs) included right heart failure (10%), surgical-related bleeding (8%), arrhythmia (8%), and driveline infection (16%). Major hemocompatibility-related AEs were limited to 3 nondisabling strokes and 1 gastrointestinal bleeding. No major device malfunction occurred during the follow-up period. CONCLUSIONS:The largest single-center experience with the leading LVAD in China shows high survival with low complication rates, demonstrating that CH-VAD is safe and efficient in providing long-term support for patients with end-stage heart failure.

Purpose: Early right heart failure (RHF) remains a major source of mortality after left ventricular assist device (LVAD) implantation, yet current clinical indicators and scoring systems for the early prediction and detection of RHF face challenges in achieving a harmonious balance between accuracy, simplicity, and practicality. Previous studies have hinted at the unique role of bilirubin metabolism in the development of RHF. This research aims to explore the predictive potential of the direct bilirubin/total bilirubin (DBIL/TBIL) ratio for RHF following LVAD implantation.

Current guideline for evaluating diastolic function requires multiple parameters to identify patients with elevated left ventricular end-diastolic pressure (LVEDP). However, the intermediate result still exists and may cause LVEDP undetermined. Previous studies have shown intraventricular pressure difference (IVPDs) are required for normal LV filling, but the relationship between IVPDs and LVEDP is unknown. In this study, we analyzed the relationship between IVPDs and LVEDP in 54 patients with coronary artery disease (CAD). LVEDP was prospectively measured at the time of coronary intervention and LVEDP > 15 mmHg was considered as elevated LV filling pressure. Simultaneous echocardiographic data was collected prior to the intervention. The relative intraventricular pressure was calculated using the vector flow mapping method. The IVPD was defined as the pressure difference from the apex to the base of LV. From 54 patients presenting with CAD, elevated LVEDP occurred in 30(55.6%). To analyze the changing trend of IVPD with LVEDP, CAD patients were further divided into group I with normal LVEDP (12.7 +/- 3.1 mmHg) and group II with elevated LVEDP (26.0 +/- 7.2 mmHg). In early diastole, both isovolumic relaxation period and rapid filling period showed decreased IVPD in CAD patients, but only the reduction in isovolumic relaxation period (IVPD-IVR) was statistical different between patients with elevated LVEDP and normal LVEDP (1.03 +/- 0.42 mmHg vs. 2.25 +/- 1.21 mmHg, p < 0.01). IVPD-IVR had the best correlation with LVEDP (r=-0.499, p < 0.01) among IVPDs. Lower IVPD-IVR was associated with higher risk of elevated LVEDP. Evaluating IVPD-IVR might improve the diagnostic algorithm for predicting elevated LVEDP.

Background: Three-dimensional (3D) transesophageal echocardiography (TEE) has been successfully used in the sizing of left atrial appendage (LAA) occlusion devices, but its use has not yet been studied in LAA clip devices. We sought to develop and validate the novel use of 3D-TEE sizing in a novel LAA clip device for atrial fibrillation (AF) patients undergoing video-assisted thoracic surgery (VATS) ablation. Methods: Consecutive patients with isolated AF undergoing LAA clipping or excision during VATS ablation were included in the study between June 2021 and September 2022 at Fuwai Hospital. The patients underwent 3D-TEE examinations preoperatively and postoperatively. The VATS length, LAA clip effective length, and LAA excision margin length were recorded. A correlation analysis, intraclass correlation coefficient (ICC) analysis, and Bland-Altman plot analysis were conducted to examine the TEE parameters, VATS length, LAA clip effective length, and LAA excision margin length. Results: In total, 26 AF patients undergoing LAA clipping and 15 undergoing LAA excision were included in the study. In the LAA clipping group, in which the Atriclip size served as the control, the 3D-TEE with volumetric measurement (the perimeter-derived maximum orifice diameter) (R=0.938; ICC =0.934; Bland-Altman plot variability, 3.85%) showed the best sizing efficacy for the LAA clip device among the 3D-TEE with multiplanar reformatting sizing (the perimeter-derived maximum orifice diameter) (R=0.808; ICC =0.772; Bland-Altman plot variability, 3.85%), VATS sizing (R=0.851; ICC =0.756; Bland-Altman plot variability, 11.54%), and VATS plus 0.5-cm sizing (R=0.851; ICC =0.775; Bland-Altman plot variability, 11.54%) measurements (all P<0.001). In addition, for the distribution of matched sizing in the LAA clip group, 3D-TEE with volumetric measurement sizing (20/26) had a higher proportion than 3D-TEE with multiplanar reformatting sizing (11/26, P=0.011), VATS sizing (9/26, P=0.002), and VATS plus 0.5-cm sizing (14/26, P=0.08). Using the LAA excision margin length as the control, the mean difference in the LAA diameter was 1.17 cm [95% confidence interval (CI): 0.71-1.62 cm , P<0.001] in the maximum orifice diameter of two-dimensional-TEE, 0.15 cm (95% CI: -0.32 to 0.61 cm , P=0.523) in the perimeter-derived 3D multiplanar reformatting (the maximum orifice diameter), and 0.03 cm (95% CI: -0.47 to 0.53 cm, P=0.901) in the perimeter-derived 3D volumetric (3DV) measurement (the maximum orifice diameter), and the related Pearson correlation coefficients for these modalities were 0.760 (P=0.001), 0.843 (P<0.001), and 0.963 (P<0.001), respectively. Conclusions: Our study showed that 3D-TEE might be employed in the sizing of a novel LAA clip device using the VATS approach in patients with AF. The 3DV measurement (the perimeter-derived maximum orifice diameter) was superior to the VATS measurement. These findings might also apply to LAA VATS excision patients with AF.