Additional imaging, such as TEE, cardiac CT, or fluoroscopy, may be required when valve dysfunc- tion is suspected and in the context of the clinical pre- sentation. A schedule for surveillance TTE studies has become an established feature of long-term follow-up, although the frequency of routine studies that are per- formed in the absence of clinical change will vary as a function of valve type. Recommendation-Specific Supportive Text 1. TTE after valve implantation or repair provides an assessment of the procedural results and serves as a baseline against which comparison can be made for any change. TTE provides accurate mea- surements of transvalvular velocities and pressure gradients, as well as detection and quantitation of transvalvular and paravalvular leak.1 4 Normal transvalvular velocities and gradients vary across different types and sizes of prosthetic valves but are also affected by patient-specific factors, including body size and cardiac output. The postoperative study, recorded when the patient is asymptomatic and in a stable hemodynamic state, provides Doppler flow data for a specific valve in an individual patient. In addition, TTE pro- vides assessment of other valve disease(s), pulmo- nary artery pressure, atrial size, LV and RV size and function, and pericardial disease. 2. Bioprosthetic or repaired native valve dysfunc- tion typically presents with the insidious onset of HF symptoms or a change in the ausculta- tory findings. More abrupt and severe symptoms may occur with infective endocarditis or rupture of a valve cusp. Patients with mechanical valve dysfunction may present with HF, shock, throm- boembolic events, hemolysis, or a change in auscultatory findings. Presentation may often be acute or subacute because of thrombus forma- tion and more abrupt impairment of leaflet open- ing or closure. Attention should be directed to the trend in recent INR determinations. 