The American Society of Echocardiography (ASE) and the American College of Cardiology/American Heart Association (ACC/AHA) have released updated comprehensive guidelines for the use of transesophageal echocardiography (TEE) for the assessment of cardiac structures and implanted devices to help guide intraoperative decision-making. Transesophageal echocardiography (TEE) is a regularly employed intraoperative diagnostic and monitoring tool, offering various modalities for the rapid evaluation of valvular and aortic pathology, hemodynamic disturbances, and cardiac function. It is particularly valuable in assessing and placing mechanical circulatory support (MCS) devices, providing views often challenging to obtain through transthoracic echocardiography. Additionally, intraoperative TEE can be used for decision-making in patients with valvular disease allowing incorporation of patient-specific and situational factors. Echocardiographers can employ this information in real-time to help guide surgical treatment selection such as repair, replacement, or deferral of intervention.