An outstanding image quality and detail resolution are characteristics of the transesophageal echocardiographic approach. Transesophageal echocardiography however, is more expensive than transthoracic echocardiography and semi-invasive. Indeed a restricted use is warranted for situations where the additional information obtained is decisive for further patient management. This is the case in the evaluation of patients with unexplained cerebrovascular events, diseases in the left or right atrium, suspected endocarditis, prior to valvuloplasty or valvular reconstructive surgery, suspected prosthetic valve dysfunction and diseases of the thoracic aorta, especially aortic dissection. In most centers TEE is routinely performed during cardiac surgery. In critically ill patients TEE can be performed safely and provides important information. Future development will include even more detailed image quality, newer imaging methods allowing assessment of myocardial perfusion and especially threedimensional imaging.