It is suggested that TEA improves the myocardial metabolic supply and demand relationship and thereby affords myocardial protection. This is supported by a reduction in myocardial stunning and infarct size in animal models and by improved perioperative hemodynamic stability and reduced markers of ischemic injury in clinical studies. Other beneficial effects include reliable stress response attenuation with a reduction in postoperative analgesia resulting in improved pulmonary function following cardiac surgery. It is furthermore clear that to achieve improved outcome, it is essential that the use of TEA be extended well into the postoperative period as an analgesic component of a multimodal postoperative approach, which should also include such things as early enteral feeding and mobilization. However, because of the potential risk of epidural hematoma, with possible permanent neurological injury, it is essential that the use of TEA be justified through studies showing improved outcomes (e.g., reduced major myocardial events and improved graft patency). This will require large, well-designed multicenter clinical trials and an international registry for complications. Until then, it is essential that epidural anesthesia during cardiac surgery be used cautiously, following recommended guidelines