Retained intracardiac air is a continuing hazard for cardiopulmonary bypass. M-mode transesophageal echocardiography of the left atrium, left ventricle, and aorta is a highly sensitive method for detecting retained intracardiac air bubbles. In 15 patients having valve operations and 18 having coronary bypass, M-mode transesophageal echocardiography was used to record air bubbles during and for 15 minutes after bypass. Routine air clearing methods were used: needle aspiration of the ascending aorta (combined coronary and valve operations) and left atrial, left ventricular, and aortic aspiration after careful passive chamber filling (valve operations). Air was detected in 12 of 15 (79%) patients having valve operations and two of 18 (11%) patients having coronary bypass. One with air in the aorta had visible right coronary air embolism. Three patients with positive echograms had transient central nervous system disturbances. In a further 11 patients having valve operations, an ascending aorta-venous shunt was created before bypass was discontinued, but air continued to be present in the left atrium. Finally, in seven patients, we added the following maneuvers to our routine: positive chamber filling with echocardiographic demonstration of left atrial stretching, vigorous chamber ballottement, specific echo-directed chamber aspiration, and maintenance of cardiopulmonary bypass until transesophageal echocardiography showed no retained air. Although small amounts of atrial air could still be detected for a minute or two in some patients, this technique appears finally to have eliminated significant retained air and its consequences. A sensitive technique for intracardiac air detection reveals retained air surprisingly often after cardiopulmonary bypass. There are both possible and probable adverse consequences of this air. After valve operations, it is most difficult to eliminate air from the left atrium. There are three essential elements of air removal: First is mobilization of the air; positive chamber filling, stretching of the atrial wall, and ballottement are critical. Second is removal of mobilized air; continuous ascending aorta-venous shunting and nonsuction venting of the left atrium are very important. Third is proof of elimination of air before cardiopulmonary bypass is terminated; transesophageal echocardiography is vital for this.