In 16 adult patients, we performed continuous intraoperative two-dimensional transesophageal echocardiography (2DTEE) to help elucidate the mechanism of myocardial dysfunction that accompanies liver transplantation. In 4 of the 16 patients "paradoxical" motion of the interventricular septum consistent with right ventricular failure was seen. An additional three of the 16 patients showed right atrial enlargement and right-to-left deviation of the interatrial septum. Two patients showed evidence of paradoxical embolization (one of whom had right ventricular and right atrial enlargement), and a third patient (who had right atrial enlargement) embolized a large right atrial thrombus into the pulmonary circulation. Two-dimensional transesophageal echocardiography demonstrated that isolated right ventricular failure might account for some of the hemodynamic instability seen during liver transplantation. Venous, pulmonary, and paradoxical embolization of air and thrombi documented by transesophageal echocardiography likely contribute to right heart failure.