At present, the evaluation of graft flow with conven- tional nonimaging handheld Doppler probes appears adequate (Section 8). Intraoperative evaluation of mitral regurgitation may facilitate detection of myocardial ischemia and provide guidance about the need for mitral valve annuloplasty (Sec- tion 6.7). Newer technologies, including nonimaging methods for analyzing systolic and diastolic velocity and direction and timing of regional wall motion (Doppler tissue imaging and speckle tracking), as well as real-time 3-dimensional im- aging, may facilitate the diagnosis of myocardial ischemia and evaluation of ventricular function. At present, however, their cost-effectiveness has not been determined, and they are too complex for routine use.152 154 Among different centers, the rate of intraoperative TEE use in CABG patients varies from none to routine; its use is influenced by many factors, such as institutional and practi- tioner preferences, the healthcare system and reimbursement strategies, tertiary care status, and presence of training pro- grams.155 The efficacy of intraoperative TEE is likely influ- enced by the presence of 1) LV systolic and diastolic dysfunction, 2) concomitant valvular disease, 3) the planned surgical procedure (on pump versus off pump, primary versus reoperative), 4) the surgical approach (full sternotomy versus partial sternotomy versus endoscopic or robotic), 5) its acuity (elective versus emergency); and 6) physician training and The safety of intraoperative TEE in patients undergoing cardiac surgery is uncertain. Retrospective analyses of data from patients undergoing diagnostic upper gastrointestinal endoscopy, nonoperative diagnostic TEE imaging, and intra- operative imaging by skilled operators in high-volume cen- ters demonstrate a low frequency of complications related to insertion or manipulation of the probe.164,165 Nevertheless, minor (primarily pharyngeal injury from probe insertion) and major (esophageal perforation, gastric bleeding, or late me- diastinitis) complications are reported.166,167 A more indolent complication is that of acquired dysphagia and possible aspiration postoperatively. 