Patients undergoing orthotopic liver transplantation frequently display considerable physiological changes during the procedure as a result of both the disease process and the surgery. Anaesthesia is often challenging and relies upon advanced monitoring techniques to provide data pertinent to peri-operative management. Traditionally the pulmonary artery flotation catheter has been regarded as the gold standard for cardiac output and right heart monitoring. This review examines whether trans-oesophageal echocardiography merits a place in the continuing evolution of this technically advanced and challenging anaesthetic field. Liver Transpl 12:1577–1583, 2006. © 2006 AASLD.