Surgical series have shown that the surgical results are related more to a surgeon s ability to remove all infected tissues and recon- struct functional anatomy than to the type of valve used for a replacement. Patients with prosthetic valve endocarditis complicated by paravalvular invasion, as manifested by intracar- diac abscesses, fistulae, or heart block, experi- ence high mortality rates and are rarely cured by medical treatment alone. By contrast, surgi- cal series have reported surgical survival rates of 71% in this high-risk group.9,41 44 5. Blood culture samples will typically become nega- tive after 48 hours of appropriate antimicrobial therapy, except for with methicillin-resistant S. aureus and other resistant organisms, for which it may take up to a week for cultures to become negative. Some caution is advised in patients who develop recurrent fever after an initially successful response to antibiotics because the fever could be explained by reasons other than the endocarditic valve. Ongoing infection despite antibiotic ther- apy is common with aggressive microorganisms, resulting in abscess formation, valve destruction, fistulas, or large vegetations.7,9,15,46,48 6. Optimal therapy for cardiac device IE combines complete device extraction and a prolonged course of parenteral antibiotics with complete device and lead removal, even if evidence for infection appears to be limited to the generator pocket site. A prospective cohort study using data from the ICE-PCS (International Collaboration on Endocarditis Prospective Cohort Study) showed that among patients with cardiac device IE, the rates of both concomitant valve infection and mortality are high, particularly if there is valve dysfunction. A proportional hazards regression analysis showed a survival benefit at 1 year for device removal during the initial hospitalization; device removal during the index hospitalization had died at 1 year, versus 13 of 34 (38.2%) who did not undergo device removal (HR: 0.42; 95% 7. 