TTE should be performed in all cases of suspected IE (Class I; Level of Evidence B). Repeat Echocardiography If the initial TTE images are negative and the diagnosis of IE is still being considered, then TEE should be performed as soon as possible (Table 4). Among patients with an initially positive TTE and a high risk for intracardiac complications, including perivalvular extension of infection, TEE should be obtained as soon as possible. Repeating the TEE in 3 to 5 days (or sooner if clinical findings change) after an initial negative result is recommended when clinical suspicion of IE In some cases, vegetations may reach a detectable size in the interval, or abscess cavities or fistulous tracts may become evident. An interval increase in vegetation size on serial echocardiography despite the administration of appro- priate antibiotic therapy has serious implications and has been associated with an increased risk of complications and the need for surgery.60 Repeat TEE should be done when a patient with an initially positive TEE develops worrisome clinical features during antibiotic therapy. These features, including unexplained progression of heart failure symptoms, change in cardiac murmurs, and new atrioventricular block or arrhyth- mia, should prompt emergent evaluation by TEE if possible. Recommendations 1. TEE should be done if initial TTE images are nega- tive or inadequate in patients for whom there is an ongoing suspicion for IE or when there is concern for intracardiac complications in patients with an initial positive TTE (Class I; Level of Evidence B). 2. 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. 