Echocardiography has been utilized perioperatively since the 1970s and many studies have been conducted to prove its efficacy. Epicardiac echocardiography (EE) is the modality of choice when transesophageal echocardiography ( TEE) is contraindicated or when aortic atherosclerosis is suspected. Perioperative TEE has shown to be an excellent tool in the operating room for assessment, diagnosis, surgical guidance, and outcome evaluation. Pediatric surgery has also shown better surgical outcomes for congenital disease states with the guidance of TEE. The cardiac Sonographer's role in the operating room is a very important one because it involves operating the ultrasound machine and communicating image interpretations to surgeons in a timely and efficient manner. Cardiac Sonographers eager to progress in their careers can take advantage of this opportunity to enhance their clinical and educational qualifications. Technology is advancing quickly with the breakthrough of 3D and 4D TEE, where images are captured in real time, providing improved diagnoses and prognosis. This article discusses the evolution of echocardiography in the operating room and its future impact on perioperative evaluation, with attention paid to the role of cardiac Sonographers and the future clinical progression in their scope of practice.