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An unrestricted interatrial septal orifice is required in many heart diseases in order to maintain hemodynamics. A variety of interventions have been described to achieve the above goal. This review summarizes each of them briefly. Of these, balloon atrial septostomy and interatrial stenting are the most commonly performed procedures. Echocardiography plays a pivotal role not only in the preprocedural evaluation and patient selection but also in intraprocedural guidance. The outcome of the procedure can also be evaluated immediately by echo on table allowing further attempts or changes in strategy. This review highlights the role of echocardiography in improving accuracy, feasibility, and safety of these procedures.