Early surgi- cal intervention may preclude a primary or recurrent major embolic event but exposes the patient to both immediate and lifelong risks of valve replacement if the valve cannot be pri- marily repaired. At this time, the strategy for surgical inter- vention to avoid systemic embolization in IE remains specific Baddour et al Infective Endocarditis in Adults 1469 to the individual patient, with benefit being greatest in the early phase of IE when embolic rates are highest and other predictors of a complicated course (ie, recurrent embolization; heart failure; aggressive, antibiotic-resistant organisms; or PVE) are present (Table 5). The benefits of early surgery were demonstrated in the prospective, randomized trial12 that was discussed earlier in this document. Because of several limita- tions of that trial, additional study is needed before routine application of early surgery solely to reduce embolic risk can be strongly advocated. Embolic events are important prognostic indicators of IE outcomes. In 1 analysis, an embolic event was 1 of 4 early pre- dictors of in-hospital death caused by IE.285 Other independent predictors of death by logistic regression modeling among 267 consecutive patients with definite or possible IE by modified Duke criteria were diabetes mellitus, S aureus infection, and Acute Physiology And Chronic Health Evaluation (APACHE) II score. Another controversial topic is whether imaging to detect emboli should be performed in all IE patients. The current paradigm includes dedicated, anatomic imaging if there are signs or symptoms suggestive of an embolic event. There is less agreement on imaging, which can pose risks because con- trast material is usually required, in patients without symp- toms or signs of emboli, some of whom may have silent or subclinical events. In particular, should MRI of the brain be obtained in all IE patients because cerebral emboli are so com- monplace? 