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For patients with impaired cardiac function, the physiologic alterations incurred by the laparoscopic approach can produce marked, if not life-threatening, hemodynamic instability. We present such a case in a patient with hypertrophic obstructive cardiomyopathy who hemodynamically decompensated during abdominal insufflation. Guided by intraoperative transesophageal echocardiography, the cause of the intraoperative hypotension was correctly identified and treated, avoiding potential severe perioperative cardiac complications. This report demonstrates the use of intraoperative transesophageal echocardiography in noncardiac surgery as a diagnostic tool and means to guide therapeutic strategy.