Intraoperative Transesophageal Echocardiography in Cardiac Surgery: Clinical Applications, Decision-Making, and Impact on Outcomes

Intraoperative transesophageal echocardiography (TEE) has become a central component of modern cardiac surgery by providing real-time, high-resolution assessment of cardiac anatomy and physiology throughout the perioperative period. Beyond its traditional diagnostic role, intraoperative TEE directly influences surgical and anesthetic decision-making by enabling immediate detection of unexpected pathology, residual lesions, and hemodynamic instability. Accumulating evidence demonstrates that TEE-guided intraoperative assessment frequently leads to modification of surgical strategy or anesthetic management, particularly in valve surgery, aortic procedures, and complex congenital heart disease repair. In valve surgery, intraoperative TEE serves as a critical quality control tool by verifying repair adequacy and identifying residual regurgitation, which has been associated with impaired mid- and long-term durability. In aortic surgery, TEE provides rapid bedside evaluation of aortic pathology and repair adequacy, supporting timely intraoperative decision-making in high-risk settings. Additionally, intraoperative TEE plays a pivotal role in perioperative hemodynamic monitoring by allowing direct assessment of ventricular filling, contractility, and right ventricular function, thereby guiding fluid therapy, pharmacologic support, and mechanical circulatory assistance. Although limitations such as operator dependency, practice variability, and a predominance of observational data persist, the cumulative literature supports routine integration of intraoperative TEE into contemporary cardiac surgical practice. Ongoing advances in three-dimensional imaging, artificial intelligence-assisted analysis, and protocol standardization are expected to further enhance the clinical utility and reproducibility of intraoperative TEE in evolving surgical and hybrid procedures.