Transesophageal echocardiography in evaluation and management after a Fontan procedure. Transesophageal echocardiography was used in 18 patients (aged 1.6 to 34 years, mean age 12.6) to assess the immediate (5 patients) or intermediate (13 patients) results after a Fontan-type procedure. The findings were correlated with precordial echocardiographic (all patients) and cardiac catheterization (11 patients) data. Atrial shunting was documented by transesophageal studies in three patients (precordial in one patient). In two patients it was confirmed by cardiac catheterization; the third underwent reoperation based on the transesophageal study alone. Pulmonary artery obstruction was documented in three patients (precordial in one patient) and was confirmed by subsequent cardiac catheterization in all. Evaluation of anterior Fontan connections was successful in 5 of 8 patients (precordial in 6 of 8), and posterior connections in 10 of 10 patients (precordial in 5 of 10). A Glenn shunt could be evaluated in eight of nine patients (precordial in three of nine). Thrombus formation was detected by transesophageal studies in three patients (precordial in one patient); repeat studies were used to evaluate thrombolytic therapy in two. Atrioventricular valvular regurgitation (11 of 18 patients) was better defined by transesophageal than by precordial studies (5 of 18). A coronary artery fistula was identified in two cases (precordial in none). Transesophageal pulsed Doppler interrogation of pulmonary artery and pulmonary vein flow patterns consistently allowed a detailed evaluation of the Fontan circulation. Transesophageal echocardiography is an important diagnostic and monitoring technique after the Fontan procedure. In this series, it was far superior to precordial ultrasound evaluation and of substantial additional value to cardiac catheterization. 