AbstractIntroductionTransseptal puncture (TSP) is routinely performed for left atrial ablation procedures. The use of a three‐dimensional (3D) mapping system or intracardiac echocardiography (ICE) is useful in localizing the fossa ovalis and reducing fluoroscopy use. We aimed to compare the safety and efficacy between 3D mapping system‐guided TSP and ICE‐guided TSP techniques.MethodsWe conducted a prospective observational study of patients undergoing TSP for left atrial catheter ablation procedures (mostly atrial fibrillation ablation). Propensity scoring was used to match patients undergoing 3D‐guided TSP with patients undergoing ICE‐guided TSP. Logistic regression was used to compare the clinical data, procedural data, fluoroscopy time, success rate, and complications between the groups.Results Sixty‐five patients underwent 3D‐guided TSP, and 151 propensity score‐matched patients underwent ICE‐guided TSP. The TSP success rate was 100% in both the 3D‐guided and ICE‐guided groups. Median needle time was 4.00 min (interquartile range [IQR]: 2.57–5.08) in patients with 3D‐guided TSP compared to 4.02 min (IQR: 2.83–6.95) in those with ICE‐guided TSP (p = .22). Mean fluoroscopy time was 0.2 min (IQR: 0.1–0.4) in patients with 3D‐guided TSP compared to 1.2 min (IQR: 0.7–2.2) in those with ICE‐guided TSP (p < .001). There were no complications related to TSP in both group.ConclusionsThree‐dimensional mapping‐guided TSP is as safe and effective as ICE‐guided TSP without additional cost.