Transthoracic echo (TTE) is the first line diagnostic imaging study for patients with known or suspected valvular heart disease. TTE allows accurate assessment of valve anatomy and etiology, concurrent valve disease, and associated abnormalities. Doppler echocardiography provides accurate noninvasive determination of valve hemodynamics. In addition, transesophageal echo is indicated in some patients for optimal imaging of the valve due to location.⁸ For evaluation of patients who would benefit from LAAO, echocardiography is used by most centers to evaluate left atrial appendage size, anatomy and for existence of thrombus. A review of implanting programs showed that TTE was the most common imaging modality before the procedure and fluoroscopy guidance together with 2D TEE was the most common modality combination during the procedure.⁹