Patients with coronary artery disease have an increased risk of developing intra-operative myocardial ischaemia and peri-operative myocardial infarction. Pre-operative identification of patients at risk of developing peri-operative myocardial ischaemia is often difficult or even impossible due to the inability of the patient to perform an exercise test. For those unable to perform physical exercise a system has recently been described combining transoesophageal echocardiography with simultaneous transoesophageal atrial pacing via the same probe to detect pacing-induced wall motion abnormalities, a sign of coronary artery disease. In a prospective study, 20 patients with clinically suspected coronary artery disease undergoing hip replacement were examined pre-operatively by transoesophageal stress echocardiography. During the subsequent operation the incidence of intra-operative ischaemia was evaluated again in all 20 patients by transoesophageal echocardiography. In eight of the 20 patients (40%) wall motion abnormalities could be induced by transoesophageal stress echocardiography pre-operatively. Intra-operative wall motion abnormalities occurred in six of these eight patients. In two patients with wall motion abnormalities induced by transoesophageal stress echocardiography no abnormalities occurred during surgery. However, in those in whom wall motion abnormalities did occur during operation they occurred in the same left ventricular segment as those initiated by stress echocardiography. None of the patients without pre-operatively inducible wall motion abnormality developed them during surgery. No patient developed a myocardial infarction intra- or post-operatively. Thus, preoperative transoesophageal stress echocardiography is a valuable technique for the detection of patients who may develop ischaemic wall motion abnormalities during surgery.(ABSTRACT TRUNCATED AT 250 WORDS)