ACC/AHA guid- ance on the management of patients with IE has been published in separate guidelines.33,463 In patients with IE and recurrent embolic stroke or TIA despite antibiotic therapy, an early consid- eration for surgery (during the index hospitaliza- tion and before completion of a full therapeutic course of antibiotics) is reasonable if there is no evidence of intracranial hemorrhage or extensive 7. Vegetation size represents an important risk fac- tor for systemic embolization in patients with In a multicenter prospective study includ- ing 384 consecutive patients with IE who under- went TEE, embolic complications occurred in 131 cases (34.1%). Of these, 28 patients (7.3%) had an embolic event after the institution of adequate antibiotic therapy. Vegetation length was larger in patients with new embolic events (after initiation of antibiotic therapy) than in those without (median, 15.5 mm versus 9 mm, respectively; P<0.001). A vegetation length threshold of 10 mm was iden- tified as having the highest predictive value for embolic events while on adequate antibiotic ther- In a small randomized trial including 76 patients with left-sided IE, severe mitral valve or aortic disease, and large vegetations (>10 mm), early surgery (within 48 hours of randomization) was associated with a significant reduction of the composite end point of in-hospital death or embolic with conventional treatment.464 8. 