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The rapid expansion of less invasive surgical and transcatheter cardiovascular procedures for a wide range of cardiovascular conditions, including coronary, valvular, structural cardiac, and aortic disease has been paralleled by novel three-dimensional (3-D) approaches to imaging. Three-dimensional imaging allows acquisition of volumetric data sets and subsequent off-line reconstructions along unlimited 2-D planes and 3-D volumes. Pre-procedural 3-D imaging provides detailed understanding of the operative field for surgical/interventional planning. Integration of imaging modalities during the procedure allows real-time guidance. Because computed tomography routinely acquires 3-D data sets, it has been one of the early imaging modalities applied in the context of surgical and interventional planning. This review describes the continuum of applications from pre-operative planning to procedural integration, based on the emerging experience with computed tomography and rotational angiography, respectively. At the same time, the potential adverse effects of imaging with X-ray-based tomographic or angiographic modalities are discussed. It is emphasized that the role of imaging guidance in this context remains unclear and will need to be evaluated in clinical trials. This is in particular true, because data showing improved outcome or even non-inferiority for most of the emerging transcatheter procedures are still lacking.