Approximately 30–40% of ischemic strokes are believed to be cardiogenic in origin. Despite its poor sensitivity transthoracic echocardiography (TTE) is widely used to rule out cardiac source of emboli. Recently transesophagel echocardiography (TEE) has shown higher sensitivity for detecting potential sources of embolic stroke. However, the extent to which TEE findings alter the initial treatment plan is unclear. We evaluated 112 patients who were referred for TTE to rule out cardiac sources of stroke by both TTE and TEE. Nineteen (17%) had a positive TTE compared to 64 (57%) with positive TEE. In addition, 11 of the 64 (17%) with abnormal TEE had findings which clearly redirected the treatment plan (myxoma=4; thoracic aortic mass=1; native valve vegetation=1; prosthetic valve vegetation=1; valvular masses=3). One patient whose TTE was interpreted as left atrial (LA) myxoma had atrial septal aneurysm (ASA) byTEE. This ASA protruded into the LA and simulated as a “mass” on the TTE. A higher rate of detection of potential source for emboli was noted by TEE compared to TTE for ASA (10 vs 4); left atrial (lA) and LA appendage thrombi (20 vs 3); LA myxoma (4 vs 2); vegetation (2 vs 1); patent foramen ovale (4 vs 0); spontaneous echo contrast effect (11 vs 1) and aortic debris (10 vs 0). These observations suggest increased ability of TEE in the detection of potential cardiac sources of emboli with significant impact on the treatment strategy. Whether TEE should be the initial choice of test in patients with suspected systemic emboli remains to the defined.