This includes those who have had chest wall disruptions from previous surgery or from trauma, who have had placement of intracardiac prosthetic material, or who have congenital or acquired anomalies of the thoracic cage. Although information in pediatric patients is not well developed, data from series in adult patients suggest that intracardiac echocardiography (ICE) may also be useful in selected circumstances such as potential pacemaker-lead infections and post percutaneous prosthetic valve implanta- tions. Patients with chronic lung disease of various patho- geneses may also have limited acoustic windows via TTE, which would make TEE the preferred approach. Narducci et recently reviewed their experience with the use of ICE in the diagnosis of IE involving implantable electronic devices (pacemakers and leads). Limited data confirm the utility of ICE as a diagnostic tool in such cases and perhaps its supe- riority as a diagnostic tool for this clinical circumstance. ICE added incremental value to TEE and other methodologies in particularly in patients with a probable diagnosis of IE based on the Duke criteria but in whom the TEE was negative.100 To date, these data have not been rep- licated specifically in a pediatric series, although at least 1 case report has been published advocating ICE superiority in a pediatric case of pacemaker-related IE.101 ICE has not been demonstrated thus far to be of additional value in the diagnosis of shunt-related IE in childhood. For this condition, definitive studies demonstrating enhanced accuracy for any particular modality are needed. Echocardiography is particularly important for serial stud- ies in a patient with known or suspected IE. 