Progressive congestive heart failure usually is caused by worsening valvular regur- gitation, often accompanied by ventricular dysfunction. Poor ventricular function is associated with an increased surgical Urgent surgery in patients with moderate to severe heart failure improves the likelihood of survival and preservation of cardiac function.137 In general, for patients with IE, the degree of illness is not considered a limitation to surgical intervention because the alternative, to delay or defer surgery, can have dire consequences. Periannular extension of infection also increases the risk of congestive heart failure.138,139 The greatest risk for this complication exists in aortic valve endocarditis. Periannular infections also cause fistulous tracks into the pericardium, as well as between cardiac chambers or vascular structures. Such abscesses or fistulae usually do not respond to medi- cal management alone and require surgical treatment. Sinus of Valsalva aneurysms may occur with rupture into any of the cardiac chambers.140 Clinical signs and symptoms of extension of infection beyond valve leaflets are nonspe- cific and include persistent bacteremia or fever, recurrent emboli, heart block, worsening congestive heart failure, or new pathological murmurs in patients receiving appropriate Surgicallycreatedshuntsorintracardiacconduitsareapoten- tial source for complications of IE. Because these connections Table 8. 