If there is a high suspicion of IE despite an initial negative TEE, then a repeat TEE is recommended in 3 to 5 days or sooner if clinical findings change (Class I; Level of Evidence B). 3. Repeat TEE should be done after an initially posi- tive TEE if clinical features suggest a new develop- ment of intracardiac complications (Class I; Level of Evidence B). Intraoperative Echocardiography Preoperative surgical planning for patients with IE will ben- efit from echocardiographic delineation of the mechanisms of valvular dysfunction or regions of myocardial abscess forma- tion (Table 5). The use of aortic homografts is facilitated by preoperative estimates of annular size, which allow the selec- tion of appropriately sized donor tissues.61,62 Intraoperatively, echocardiographic goals include assessment of not only Table 4. Use of Echocardiography During Diagnosis and Treatment of Endocarditis Early Echocardiography as soon as possible (<12 h after initial evaluation) TEE preferred; obtain TTE views of any abnormal findings for later comparison TTE if TEE is not immediately available TTE may be sufficient in small children Repeat echocardiography TEE after positive TTE as soon as possible in patients at high risk for complications TEE 3 5 d after initial TEE if suspicion exists without diagnosis of IE or with worrisome clinical course during early treatment of IE Intraoperative Prepump Identification of vegetations, mechanism of regurgitation, abscesses, fistulas, and pseudoaneurysms Postpump Confirmation of successful repair of abnormal findings Assessment of residual valve dysfunction Elevated afterload if necessary to avoid underestimating valve insufficiency or presence of residual abnormal flow Completion of therapy Establish new baseline for valve function and morphology and ventricular size and function TTE usually adequate; TEE or review of intraoperative TEE may be needed for complex anatomy to establish new baseline TEE indicates transesophageal echocardiography; and TTE, transthoracic echocardiography. 