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Anesthesia for orthotopic liver transplantation (OLT) is challenging for any anesthesiologist as the patients undergoing this procedure are among the most critically ill. Adding to the underlying complexity of OLT management is the rare complication of an intracardiac thrombus (ICT). Intracardiac thrombi can present following liver allograft reperfusion resulting in high morbidity and mortality. Currently there is no consensus treatment for ICT, and the gold standard for diagnosis is intraoperative transesophageal echocardiography (TEE); these 2 factors lead to a dangerous amalgam of the difficulty in diagnosing and treating the disease. We describe 2 separate cases in detail of ICT formation during OLT that were recognized and diagnosed with intraoperative TEE. These 2 cases highlight the important role of TEE in the management of ICT. A thorough literature review that follows analyzes our current understanding of ICT during OLT and the vital function of TEE by every anesthesiologists regardless of formal TEE training. Broader use of TEE during all OLTs can help narrow the anesthesiologist's differential diagnosis during the acute phases of transplantation and should be considered in all liver transplant surgeries.

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