Over the past several decades, cardiac surgical practice has changed considerably. As the prominence of simple coronary artery bypass grafting (CABG) has waned, the complexity of cardiac surgical procedures has significantly increased. Patients are returning to the operating room (OR) to have revisions of their original procedures, such as those with dysfunctional prosthetic valves, occluded coronary grafts, and adults with congenital heart disease. Many valves in which prosthetic replacement was previously performed are now being repaired. In addition, the majority of patients present with a variety of comorbidities such as abnormalities of left and right ventricular function, diabetes, renal insufficiency, pulmonary hypertension, and cerebrovascular disease. Surgeons and anaesthetists are therefore requiring more sophisticated, real time assessments of procedural success.

The use of intraoperative transoesophageal echocardiography (TOE) began in the 1980s, with M mode and subsequently two dimensional TOE, and in this initial period was used almost exclusively for the monitoring of left ventricular systolic function before and after CABG. Since that time, TOE has become an integral part of the intraoperative management of patients presenting for a variety of cardiac surgical procedures, while maintaining its pre-eminence as a monitor of ventricular function. In 2003, a committee under the auspices of the American College of Cardiology (ACC), the American Society of Echocardiography (ASE), and the American Heart Association (AHA) presented guidelines for the use of echocardiography,1 including the use of intraoperative TOE (box 1), building on guidelines published by the American Society of Anesthesiologists (ASA), and the Society of Cardiovascular Anesthesiologists (SCA).2