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. the obviously dysfunctional valve but also the other valves and contiguous structures. Post cardiopulmonary bypass images should confirm the adequacy of the repair or replace- ment and document the successful closure of fistulous tracts. Perivalvular leaks related to technical factors should be docu- mented to avoid later confusion about whether such leaks are the result of recurrent infection. During postpump imaging, it is often necessary to augment afterload to reach representative ambulatory levels to avoid underestimation of regurgitant jet size and significance and to ensure that abnormal communi- cations were closed.63 Afterload augmentation, however, may not mimic actual awake physiology and may still lead occa- sionally to an inaccurate evaluation of the awake postopera- tive hemodynamic state. 