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. Echocardiography at the Completion of Therapy All patients who have experienced an episode of IE remain at increased risk for recurrent infection indefinitely. Many believe that it is extremely important for the future care of these patients to establish a new baseline for valvular morphology, including the presence of vegetations and valvular insufficiency, once treatment has been completed. Documentation of heart rate, heart rhythm, and blood pres- sure at the time of echocardiographic study is important because changes in these conditions may explain future differences in valvular insufficiency independent of pathol- ogy (Table 4). TTE is reasonable for this evaluation because spectral Doppler interrogation for functionality metrics is more thorough than TEE. TEE, however, may be mer- ited to define the new baseline in some patients with poor acoustic windows or complicated anatomy such as after extensive debridement and reconstruction. Although intra- operative postpump TEE views may be adequate for this new baseline, they should be reviewed for adequacy and repeated if necessary. Some patients will have significant valvular dysfunction at the end of otherwise successful antimicrobial treatment that will require eventual valvular surgery. Posttreatment echocardiography can guide both medical management and the discussion of the appropriate timing of such interventions. Recommendation 1. TTE at the time of antimicrobial therapy comple- tion to establish baseline features is reasonable (Class IIa; Level of Evidence C). 