William J McIver, Sadie Dillon, Keelie Schofield, Jack Merritt, Elizabeth Morgan, Mansoor N Bangash, Dhruv Parekh
We aimed to evaluate the feasibility, diagnostic yield, accuracy, impact on management and clinical outcomes of focused transthoracic echocardiography (fTTE) in preoperative assessment. Medline, Embase and Cochrane Trials were searched to 19 January 2026. Studies evaluating preoperative fTTE were included. Cardiac surgery, examinations performed by cardiologists or cardiac physiologists, and intraoperative or postoperative examinations were excluded. Screening and data extraction were performed independently by two reviewers. Risk of bias was assessed for comparative effectiveness studies. Thirty-five studies involving 3728 patients were included. Study populations, scanning protocols and operator experience were highly heterogeneous. Median feasibility was 92.5%, with examination times of 3-16 min. Cardiac abnormalities were identified in 22-64% of patients. No formal diagnostic-accuracy studies were identified; agreement with formal TTE was variable and clinically important missed diagnoses were reported. Step-up and step-down changes in management occurred in 48 (21-54) % and 20 (1-49) % of patients, respectively. Three studies comparing plans before and after fTTE found no overall change in anaesthetic management. Individual changes in management included increased arterial-line use and reduced postoperative intensive-care admission. Four randomised trials found that echocardiography-guided pre-induction fluid therapy reduced post-induction hypotension. Three randomised trials in emergency surgical populations showed no improvement in mortality or morbidity compared with standard care. Preoperative fTTE is feasible and can identify clinically relevant cardiac and haemodynamic abnormalities and influence perioperative management. However, performance is operator- and setting-dependent, diagnostic-accuracy evidence is sparse, and benefit for patient-centred outcomes remains unproven.