Only 1 study examined the role of valve surgery After adjustment for differences in clinical char- acteristics and survival bias, early valve replacement was not associated with lower mortality compared with medical therapy in the overall cohort. Subgroup analysis indicated a lower in-hospital and 1-year mortality with early surgery only in the group of patients with the highest surgical propensity. Table 17 summarizes the characteristics of rigorously con- ducted observational studies that support the role of surgery in IE management. Indications for Surgery Decisions on surgical intervention are complex and depend on many clinical and prognostic factors257 262 that vary among patients, including infecting organism, vegetation size, presence of perivalvular infection, presence of embolism or heart failure, age, noncardiac comorbidities, and available surgical expertise. There is a paucity of evidence available to define the optimal timing of valve surgery. Decisions on the indication and timing of surgical intervention should be determined by a multispecialty team with expertise in cardiology, imaging, cardiothoracic sur- gery, and infectious diseases.261 Recommendations for early sur- gery in patients with recurrent emboli and persistent vegetations have generally been enacted after clinical events. Whether recur- rent, asymptomatic emboli detected on advanced imaging stud- ies should influence decision making should be considered on an individual basis. Risk stratification models such as the Society of Thoracic Surgeons Endocarditis Score are available to predict morbidity and mortality risks in IE patients after valve surgery and to assist in decision making and patient counseling.260 Early Valve Surgery in Left-Sided NVE: Recommendations 1. Early surgery (during initial hospitalization and before completion of a full course of antibiotics) is indicated in patients with IE who present with valve dysfunction resulting in symptoms or signs of heart failure (Class I; Level of Evidence B). 2. 