Surgery for patients with perivalvular extension of IE is directed toward eradication of the infection and correction of hemodynamic abnormalities. Drainage of abscess cavities, excision of necrotic tissue, and closure of fistulous tracts often accompany valve replacement or repair surgery.309 Although valve replacement is usually required, its successful performance may be compromised by extensive destruction of the periannular supporting tissues. Under these conditions, human aortic homo- grafts, when available, can be used to replace the damaged aor- tic valve and to reconstruct the damaged aorta.310,311 Homografts have a constant but low incidence rate of IE.312 Some groups have advocated the use of stentless or mini-stented aortic valve prostheses with debridement in the same clinical scenario, par- ticularly if homografts are not readily available.313 Recommendation 1. TEE is recommended for the initial assessment of any patient suspected of having perivalvular exten- sion of IE (Class I; Level of Evidence B). Metastatic Foci of Infection Similar to embolic complications, metastatic foci of infec- tion frequently occur in IE and can greatly affect management strategies, in particular timing of valve surgery, duration of antimicrobial therapy, and need for invasive interventions (usually surgical or interventional radiological drainage). Much like embolic events, metastatic foci of infection either can remain asymptomatic or may cause major clinical signs or symptoms. In the latter case, sustained fever can be a valu- able clue, particularly when bloodstream infection has been cleared or in cases when bloodstream infection persists despite adequate antimicrobial coverage. In addition, distinguish- ing bland infarction caused by an embolus from a metastatic focus (abscess) sometimes can be difficult. In patients who are symptomatic, a diagnostic evaluation including radiologi- cal, ultrasonographic, and invasive procedures such as joint aspiration for both diagnostic and therapeutic reasons is rec- ommended. 