The clinical value of transesophageal echocardiographic (TEE) monitoring of cardiac function during abdominal aneurysmal graft surgery was studied in 10 patients with atherosclerotic abdominal aortic aneurysm (AAA) and 12 patients with arteriosclerosis obliterans (ASO). None of the patients had a previous ischemic event. The subjects consisted of 3 women and 19 men; mean age was 65 years; range, 40 to 87 years. A transgastric approach was used to obtain the optimal left ventricular (LV) short-axis view at the level of the papillary muscle. Studies of pressure and measurement of cardiac output (CO) were carried out using Swan-Ganz catheterization and the thermodilution method. Rapid hemodynamic responses to abdominal aortic clamping, unclamping, and bleeding were monitored by two-dimensional and continuous-wave Doppler imaging. Abdominal aortic clamping caused blood pressure to increase from 133±14 to 155±18 mm Hg and pulmonary wedge pressure to increase from 10±2.5 to 12±2.6 mm Hg. The LV diastolic dimension increased from 45±6 to 48±8 mm immediately after aortic clamping but soon returned to its baseline value. Aortic unclamping produced a reversed reaction: Vascular resistance increased temporarily, and cardiac output decreased on aortic clamping. The change-ratio was more prominent in the AAA group than in the ASO group, however. Unexpected bleeding from a surgical field of more than 300 ml caused abrupt LV collapse, and blood transfusion was promptly started before drop in blood pressure was detected. Transient LV wall asynergy (hypokinesis) was found in 4 (18%) of 22 cases, but no evidence of new myocardial ischemia was confirmed by electrocardiography. We conclude that intraoperative TEE during abdominal aortic surgery is useful in detecting LV wall motion abnormality in high-risk patients with ischemic heart disease.