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. Although retrospective analyses of postoperative cardiac surgical patients with clinically mani- fest esophageal dysfunction have identified TEE use as a risk factor,168 170 such dysfunction also has been reported in subjects in whom TEE was not used.171 Advanced age, prolonged intubation, and neurological injury seem to be risk factors for its development. The significance of the incidental intraoperative detection and repair of a patent foramen ovale, a common occurrence, is controversial.172 A 2009 observa- tional analysis of 13 092 patients (25% isolated CABG; 29% CABG or other cardiac procedure), of whom 17% had a patent foramen ovale detected by TEE (28% of which were repaired), reported an increase in postoperative stroke in the patients who had patent foramen ovale repair (OR: 2.47; 95% CI: 1.02 to 6.0) with no improvement in long-term 2.1.8. Preconditioning/Management of Myocardial Ischemia: Recommendations Class I 1. Management targeted at optimizing the determinants of coronary arterial perfusion (eg, heart rate, diastolic or mean arterial pressure, and right ventricular or LV end-diastolic pressure) is recommended to reduce the risk of perioperative myocardial ischemia and infarc- tion.53,174 177 (Level of Evidence: B) Class IIa 1. Volatile-based anesthesia can be useful in reducing the risk of perioperative myocardial ischemia and infarction.178 181 (Level of Evidence: A) Class IIb 1. 