IE indicates infective endocarditis; IgG, immunoglobulin G; and spp, species. Adapted from Durack DT, et al,2 and Kupferwasser LI, et al.3 CLINICAL STATEMENTS AND GUIDELINES modalities involved, ideally at centers with immediate access to cardiac surgery during the initial observation stages of the disease. With the emerging use of telemedicine, it may be rea- sonable to manage patients with lower-acuity IE in a center without on-site multispecialty care by telecommunication with a Heart Valve MDT and infectious disease specialists, with rapid transfer of the patient to a Comprehensive Valve Center 5. The presence of valvular vegetation is a major criterion in the diagnosis of IE. TTE has a sen- sitivity between 50% and 90% and a specific- ity >90% for detection of vegetations in native valve endocarditis. TTE has a sensitivity of only 36% to 69% in prosthetic valve endocarditis, but TTE still has a role in these patients for detection and quantitation of valve dysfunction (even in the challenging situation of regurgitation in the mechanical prosthetic mitral valve, for which a proximal convergence zone may provide impor- tant evidence for a paravalvular leak), evalua- tion of ventricular size and systolic function, and estimation of pulmonary pressures. TTE exhibits superior imaging over TEE for the anterior aspect of a prosthetic aortic valve, which is commonly shadowed by the valve on TEE. TTE also allows measurement of aortic transvalvular velocity/ gradient, which is not always possible on TEE. Although TTE will not definitively exclude veg- etations or abscesses in IE, it can identify very high-risk patients, establish the diagnosis, and guide early treatment decisions (Figure 8).14,19 23 6. The sensitivity of TEE in native valve endocarditis ranges from 90% to 100%, with sensitivity ranges slightly lower in prosthetic valve endocarditis. 