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Perioperative transoesophageal echocardiography (TOE) was introduced from cardiology into cardiac anaesthesia in the 1980s. Initially TOE was used mainly as a monitor of left ventricular ischaemia, but now provides real-time dynamic information about the anatomy and physiology of the whole heart. TOE is of value in the management of patients undergoing procedures including cardiac valvular repair, surgery for endocarditis, surgery of the thoracic aorta, and may contribute useful information in a wide range of cardiac pathology. It is also useful in guiding therapy in haemodynamically unstable patients in the operating room and the intensive care unit. TOE is relatively cheap and non-invasive, but it should not be used as a stand alone device but as a tool which provides data in addition to the data acquired from other forms of monitoring. The use of TOE carries not only the benefits of a rapid and effective investigation, but also risks associated with the procedure itself and the burden of providing training and experience for practitioners. The establishment of TOE in perioperative cardiac anaesthetic care has resulted in a significant change in the role of the anaesthetist who, using TOE, can provide new information which may change the course and the outcome of surgical procedures.