The highest annualized risk for IE was found in children who had had repair or palliation of cyanotic CHD. The greatest risk among those patients was for those who had either undergone surgery for obstruction to pul- monary blood flow or had prosthetic aortic valve replacement. In a follow-up of the series of Oregon residents, the highest inci- dence of IE in postoperative patients has been in the cohort with aortic valve stenosis, and this has increased over time, with a Endocarditis may manifest as a late complication, with presentation years after congenital heart surgical repair, and may be associated with a fulminant course or antibiotic failure.14,15 The incidence of IE in the first postoperative month is low for most defects and increases with time after surgery. An exception to this trend is that when prosthetic valves or conduits are used in surgical repairs and hemodynamic prob- lems persist, the risk of IE is high even in the immediate post- operative period (first 2 weeks after surgery).12 Two recently published studies showed a 25% incidence of previous cardiac surgery in patients with congenital heart disease who required surgery during active IE.16,17 Russell et al18 reported 34 patients who met indications for surgical management of IE (of whom 37% had prior cardiac surgery) from a 21-year single-center review through 2011 at Children s Memorial Hospital, Chicago, IL. Five had opera- tive mortality, and all deaths occurred in infants, with a mean age of 2.5 months. The infective organisms were identified in 86% of cases, with the most common being S aureus (n=8) and viridans streptococci (n=6). The Ross operation was per- formed successfully in 5 children with severe aortic valve dis- ease. Ten of the 34 patients required reoperations at a later time. 