A comprehensive epicardial echocardiographic and epiaortic ultrasonographic examination can be performed efficiently and safely,12 and may be the most practical intraoperative imaging technique when a TEE probe cannot be inserted or when probe placement is contraindicated. In addition, these techniques may offer better windows for imaging anterior cardiac structures including the aorta, AV, pulmonic valve, and pulmonary arteries, and therefore they may have a favorable influence on perioperative surgical decision making.13–15 Rosenberger et al analyzed the medical records of 6051 consecutive cardiac surgical patients who underwent epiaortic ultrasonography to determine a potential impact on intraoperative surgical decision making.16 The overall impact of epiaortic ultrasonography on surgical decision making was 4.1%, and included a change in the technique for inducing cardiac arrest during cardiopulmonary bypass in 1.8%, aortic atherectomy or replacement surgery in 0.8%, requirement for off-pump coronary artery bypass grafting in 0.6%, avoidance of aortic cross-clamping and use of ventricular fibrillatory arrest in 0.5%, change in arterial cannulation site in 0.2%, or avoidance of aortic cannulation in 0.2%. In addition, the authors noted that the overall stroke rate was lower in patients in whom intraoperative epiaortic ultrasonography was performed, compared with all patients undergoing cardiac surgical procedures. Nonetheless, epicardial and epiaortic imaging do have certain limitations, including a requirement for a sternotomy to permit direct access to the anterior surface of the heart and aorta, the inability to perform continuous monitoring, and the requirement for at least a brief interruption of the surgical procedure. Despite these limitations, a fundamental understanding of the skills required to obtain and interpret epicardial echocardiographic and epiaortic ultrasound images is an advantageous adjunct to intraoperative TEE in performing a comprehensive intraoperative echocardiographic examination.