Surgical intervention is reasonable for patients with the fol- lowing complications: right heart failure secondary to severe tricuspid regurgitation with poor response to medical therapy, sustained infection caused by difficult-to-treat organisms (ie, fungi, multidrug resistant bacteria) or lack of response to appropriate antimicrobial therapy, and tricuspid valve vegeta- tions that are 20 mm in diameter and recurrent pulmonary embolism despite antimicrobial therapy. Valve repair rather than replacement should be performed when feasible. If valve replacement is performed, then an individualized choice of prosthesis by the surgeon is reasonable.263,264 Recommendations 1. Surgical intervention is reasonable for patients with certain complications (Class IIa; Level of Evidence C). 2. Valve repair rather than replacement should be per- formed when feasible (Class I; Level of Evidence C). 3. If valve replacement is performed, then an individu- alized choice of prosthesis by the surgeon is reason- able (Class IIa; Level of Evidence C). 4. It is reasonable to avoid surgery when possible in patients who are IDUs (Class IIa; Level of Evidence C). Valve Surgery in Patients With Prior Emboli/ Hemorrhage/Stroke The timing of valve surgery in IE patients with stroke remains controversial. Stroke is an independent risk factor for post- operative mortality in IE patients. After stroke, neurological deterioration can occur as a result of hemorrhagic transforma- tion with anticoagulation during cardiopulmonary bypass or exacerbation of cerebral ischemia attributable to hypotension during cardiac surgery. The risk of intracranial hemorrhage is dependent on several factors, including extent and size of infarction, whether it is ischemic or hemorrhagic, and the exact timing of surgery. One clinical quandary is whether early valve surgery can be safely performed within 7 days after a stroke or if it is better to postpone surgery for at least 1 week. No randomized trials have addressed this conundrum. 