A meta-analysis that included 64 reported patients with Candida IE who did not undergo valve surgery because they were deemed to be unacceptable surgical candidates supports the notion that fluconazole suppressive therapy is useful; 20 of 21 patients (95%) who were ultimately treated with long-term suppressive therapy survived during follow-up, which was 6 Recommendations 1. Valve surgery should be done in most cases of fungal IE (Class I; Level of Evidence B). 2. After completion of initial parenteral therapy, life- long suppressive therapy with an oral azole is rea- sonable (Class IIa; Level of Evidence B). Surgical Management There is a prevailing opinion that valve surgery is crucial for optimal therapy in selected patients with complicated IE.247 249 In a systematic review5 of 15 population-based IE investiga- tions from 7 countries, after adjustment for country, the pro- portion of IE cases undergoing valve surgery increased 7% between 1969 and 2000. In surveys involving population- and international multicenter cohorts,10,11 both NVE and PVE patients undergo valve surgery during the active phase of IE (during initial hospitalization before com- pletion of a full therapeutic course of antibiotics). Although valve replacement surgery has served as an important option in the management of individual IE cases, only 1 small, randomized trial17 has been performed to date to examine the role of valve surgery in the management of IE. In this trial, 76 patients with left-sided NVE, severe valve regur- gitation without heart failure, and vegetations >10 mm were assigned to early surgery within 48 hours or to conventional treatment. Although the authors17 report a reduction in the composite outcome of in-hospital deaths and embolic events with early surgery (3% versus 23%), the differences between the 2 groups were driven by a significant decrease in embolic events with early surgery. 