The diagnosis of congenital heart disease de novo in adults is now uncommon. Increasing numbers of children with congenital heart disease are surviving to adulthood, leading to the development of adult congenital heart disease as a distinct subspecialty.1Nevertheless, adults with congenital heart disease still present to general cardiologists—as an initial presentation, for geographical or logistic reasons, during acute or concurrent illness, or through loss of regular follow up. Echocardiography is the mainstay of diagnostic imaging in adult congenital heart disease—its role in the spectrum of congenital heart disease most often encountered in adults has been reviewed comprehensively.2 However, precordial windows in these patients are often suboptimal because of previous surgery, chest deformity or lung disease. Multiplane transoesophageal echocardiography (TOE) has proven to be of great value in adult congenital heart disease because of its high resolution, clear acoustic windows, proximity to posterior cardiac structures, and comprehensive imaging planes.3

In the diagnosis of congenital heart disease, the echocardiographic examination is performed in a detailed, systematic manner. This requires a protocol and mindset that differs from the approach often used in TOE in the adult cardiology setting. The purpose of this paper is to describe an approach to TOE in adult congenital heart disease. Specific emphasis is placed on those conditions that present in adulthood and that involve detailed TOE views of structures rarely necessary in general cardiology. The echocardiographic approach to patients who have undergone palliative procedures (for example, Mustard or Senning repairs, Fontan operations) are touched upon briefly; the echocardiographic approach to them has been discussed previously.2 The use of TOE during interventional and surgical procedures is beyond the remit of this paper.