The sensitivity of TEE in native valve endocarditis ranges from 90% to 100%, with sensitivity ranges slightly lower in prosthetic valve endocarditis. TEE is superior to TTE in the visualization of both veg- etations and paravalvular complications, which can be anatomic (eg, valve perforation, abscesses, and pericardial effusion) or hemodynamic (eg, valve regurgitation, fistulae, and intracardiac thrombi) in nature. TTE and TEE are complementary for the comprehensive evaluation of hemodynamics and anatomy in patients with IE. TEE should be used as an adjunct in patients with echocardiographic fea- tures of IE on TTE to rule out the presence of findings such as abscesses, which may alter the therapeutic approach to the management of the patient. TEE also serves a vital role in reassessment of patients with known IE with suspected clinical complica- tions, as well as a guiding tool in the intraoperative assessment and management of the patient with IE. The timing of repeat examinations depends on the clinical presentation and course and on the vir- ulence of the microorganism. Increasing vegetation size under therapy must be considered a risk fac- tor for new embolic events, whereas unchanged or reduced vegetation size under therapy may be more difficult to interpret.23,29,32 40 7. HF, paravalvular extension, and embolic events represent the 3 most frequent and severe com- plications of IE. They are also the 3 main indi- cations for early surgery, which is performed in almost 50% of cases. If signs or symptoms consistent with any of these complications exist, there should be a very low threshold for repeat imaging in these patients. TEE may miss initial paravalvular abscesses, particularly when the study is performed early in the patient s ill- ness. 