The kidney may also be affected by glomerulonephritis secondary to immune complex depositions. Although mortality from IE has clearly improved in the current era, the mortality rate remains 5% to 10% for patients (including children) with this condition,24,146,151 with the risk of death clearly related to the presence of underly- ing heart disease, as shown in a review of a large pediatric In that study, the overall mortality was only 5%, but it was 48% in patients with tetralogy of Fallot and pulmonary atresia and 8% in patients who had pros- thetic valves. Recommendations 1. In general, for patients with IE, we recommend that the degree of illness not be considered a limitation to surgical intervention, because the alternative, to delay or defer surgery, can have dire consequences (Class I; Level of Evidence B). 2. Mycotic aneurysms may occur in any systemic artery or the pulmonary arteries but are particu- larly dangerous in the cerebral circulation; surgical therapy may be considered because of the risk of rupture (Class IIb; Level of Evidence B). Indications for Surgery Cardiovascular surgery is often urgently necessary and may be lifesaving in patients with IE, but decisions regarding surgical intervention are best made when individualized. Recommendations for surgical management of pediatric IE are mostly an extension of recommendations of experts for management of adult IE. The most common reasons for surgical management of IE are congestive heart failure, progressive valve dysfunction, and embolic phenomena. 