The indications for early surgery for patients with IE include HF, persistent infection, abscess, heart block, infection with highly resistant organisms, or recurrent emboli (with persistent vegetations). In patients with implanted electronic devices, infection of the entire system is likely, even if it appears confined to the leads on imaging, and this mandates removal of the entire system to eradicate the infection. In patients with an indication for early surgery, a cerebral embolic event is not a contra- indication unless there is extensive neurological damage or intracranial hemorrhage (Figure 16). Recommendation-Specific Supportive Text 1. IE is best managed in an environment with ready access to specialists in the fields of cardiology, car- diothoracic surgery, and infectious disease, with the option for transfer of complicated cases to a Comprehensive Valve Center when needed. A risk- scoring system using the STS database has been developed to predict surgical risk in patients with IE to help better counsel patients and more objec- tively define the risks associated with surgery. One trial noted that even when surgery is indicated, women were less likely to undergo a surgical procedure than men (26% versus 47%) and that women had higher in-hospital and 1-year mortality rates than men despite similar comorbidities.1,2,4 6 CLINICAL STATEMENTS AND GUIDELINES 2. Studies have reported a 21% in-hospital mor- tality rate in patients with IE and HF who were treated with surgery versus a 45% mortality rate in those who were treated medically. In left- heart native valve endocarditis, 4 baseline fea- tures have been independently associated with 6-month mortality: 1) abnormal mental status, 2) moderate to severe HF, 3) bacterial etiology other than Viridans streptococci, and 4) medical therapy without valve surgery. 