Transesophageal echocardiography (TEE) is an important tool in the intraoperative management of patients undergoing cardiac surgery as well as high-risk patients undergoing noncardiac procedures. This technique is widely used during valve surgery and particularly valuable during valve repair. Its ability to provide a continuous assessment of ventricular performance and filling is important in patients with coronary disease or ventricular dysfunction. TEE evaluation of the thoracic aorta is useful in the diagnosis and treatment of dissection and the selection of cannulation sites free of atherosclerotic disease. In both adults and children, TEE is used to define intracardiac shunts and more complicated congenital lesions. More specialized applications include monitoring during the surgical treatment of patients with hypertrophic myopathy, pericardial disease, and cardiac masses as well as those undergoing minimally invasive bypass surgery. Currently, the technique is performed by both cardiologists and anesthesiologists. Regardless of medical background, physicians providing this service should have specialized training and experience in the field. This review will discuss current applications of intraoperative TEE and the impact of this technique on patient outcomes.