Septic vegetations at these sites may lead to dehiscence, obstruction, or distal emboli.15,143 Extracardiac complications are the result of sepsis, immune complex mediated vasculitis, and, most importantly, embolic phenomena from septic vegetations. Embolic com- plications may involve the cerebral, pulmonary, renal, splenic, coronary, or peripheral arteries, depending on the original locus of infection. Neurological sequelae include stroke, brain abscess, hemorrhage, seizures, diffuse vasculitis, or menin- gitis, and these events may occur in up to 30% of cases.144 The incidence of stroke has been reported to be 6% in pediat- and 11% in those of all ages with CHD.146 Mycotic aneurysms may occur in any systemic artery or the pulmonary arteries but are particularly dangerous in the cere- bral circulation; surgical therapy may be used because of the risk of rupture. Numerous studies in adults102,147 have shown increased risk for embolization with vegetations >10 mm, which indicates a role for early surgical intervention in those with such large vegetations. Recently, this finding was sup- ported in a pediatric study.148 The location of the vegetation may also be a factor, with mitral valve anterior leaflet lesions having a higher rate of embolization than aortic valve vegeta- Particular organisms, namely, staphylococci, pneumococci, and fungi, also carry a high risk of embolism. Most emboli occur early in the course of the illness, but an increase in the size of the vegetation while a patient is receiving effective treatment may be predictive of The kidney and spleen may be involved during IE, with infarcts or abscesses related to emboli. The kidney may also be affected by glomerulonephritis secondary to immune complex depositions. 