The timing of aortic root replacement is even more important It is clear that early aggressive aortic root replacement for active infective aortic root endocarditis with periannular abscesses is more successful than delayed last resort surgery Outcomes of Infective Endocarditis Surgery The results of the published studies on outcomes of surgery in adult IE159,160 have previously been summarized.147 The number of studies and results of databases have significantly increased in the last several years Interpretation is difficult because the majority of studies are mixing patients with heterogeneous causes and outcome measures Methods of adjustment for various confounding factors have been published.148,149 The results of surgery for pediatric IE are much better than in adults This is valid for both before 2000150,151 and after 2000.24,152,153 Currently, postoperative mortality for pediatric IE stands at approximately 10%, although some report it at 15%,154 which is comparable to that reported in adults,157 where the mortality is higher in prosthetic valve IE and S aureus IE Outcomes of right-sided IE are generally better, but this is not the case if there is additional left-sided IE.155 Results for tricuspid valve endocarditis surgery are much better156 than previously reported; there is no recurrence after tricuspid valve repair; however, there is 20% recurrence risk for prosthetic biologic tricuspid valves Risk factors for perioperative death in pediatric IE are age younger than 1 year, prematurity, fungal organisms,154 and S aureus IE.24 The suggested scoring systems for predicting in-hospital postoperative mortality for adult IE157,158 are unlikely to be appropriate for use in pediatric IE, although this remains to be tested Antithrombotic Therapy There is no indication for the initiation of antithrombotic drugs (thrombolytic, anticoagulant, or antiplatelet) in patients with active IE Recommendations for patients on oral anticoagulation with vitamin K antagonists for prosthetic valve are based on a low level of evidence: if there is no stroke or ischemic stroke, replacement of oral anticoagulation by unfractionated heparin (or lowmolecular-weight heparin) should be considered for 2 weeks (especially S aureus); if there is ischemic stroke or intracranial hemorrhage, all anticoagulation should be stopped for 2 weeks and reinitiated at a later stage only after multidisciplinary discussion Long-Term Outcome Post Resolution of Infection In pediatric IE, there is a favorable long-term evolution after resolution of infection and hemodynamic problems Pulmonary and cerebral embolism– related changes have favorable outcome in the predominant proportion of children with IE if infection is suppressed The recurrence rate is low.154 Large pediatric studies on the long-term outcomes are in demand In adults with IE, the mean recurrence risk is 9%, with most of the occurrences during the first year after the acute episode,161 being at least 15% in prosthetic valve IE.162,163 S aureus native valve IE in adults has not only worse in-hospital mortality of 25% but also reduced 5-year survival of 50%, and delayed surgery is a risk factor, along with sepsis and heart failure.164 Specific Sites, Causative Organisms, and Predisposing Factors Unusual Location Coronary fistula IE is exceptionally rare and is reported to have occurred in 4% of a large group of adult patients.165 It is usually at the venous end, it has never been reported at the arterial end, and it may involve valves It is rarely reported in children.166,167 Right heart structures may have IE related to a coronarycameral fistula.168 Mural endocarditis related to lines is possible in neonates It can be attached to a muscle bundle in the right ventricle,169,170 to the eustachian valve,171 to an additional chord of mitral valve, to the patent foramen ovale, and to intracardiac surgical patches for atrial septal defect closure172 and ventricular septal defect closure.173 There can be myocardial abscesses, including of the papillary muscle Subendothelial abscesses to the transition between superior vena cava and the right atrium related to line have also been described.174 Unusual Causative Organisms Intracellular organisms (especially Bartonella and Coxiella burnetii) have atypical clinical manifestations with prolonged course Bartonella spp are an important cause of culture-negative endocarditis, with recognized risk factors of alcoholism, homelessness, cat exposure, and preexisting valvar disease in adults; in children these risk factors are not well delineated Bartonella IE diagnosis might be difficult175,176 because the clinical picture is characterized by the following: ■ Long course ■ Negative BC (serology has to be requested) ■ Bone marrow suppression ■ More pronounced splenomegaly ■ Vasculitis imitating with antineutrophil cytoplasmic antibody positivity ■ Involvement Brucella IE is also very rare and difficult to diagnose,177–179 with the clinical picture characterized by delayed manifestations from the time of contact, arthritis, and atrioventricular block Mycobacterium tuberculosis IE is extremely rare and seen in immunocompromised people The first case in an immunocompetent child has also been published.180 Mycobacterium chimaera IE is a recently emerging pathogen that is thankfully described to have caused few cases of IE.181–184 It is genetically a member of the Mycobacterium avium complex The likely source is water from heater cooler units used in cardiac bypass units It is described in patients after open heart surgery, causing infection on prosthetic heart valves and vascular grafts It is mainly described in adults; the number of cases in children is limited to single digits It is difficult to diagnose and treat and is likely to have poor outcome The significance in pediatric IE is minimal, if any Unusual Predisposing Factors Confirmed in children ...anticoagulation should be stopped for 2 weeks and reinitiated at a later stage only after multidisciplinary discussion Long-Term Outcome Post Resolution of Infection In pediatric IE, there is a favorable long-term evolution after resolution of infection and hemodynamic problems... related changes have favorable outcome in the predominant proportion of children with IE if infection is suppressed The recurrence rate is low.154 Large pediatric studies on the long-term outcomes are in demand In adults with IE, the mean recurrence risk is 9%, with most of the... to single digits It is difficult to diagnose and treat and is likely to have poor outcome The significance in pediatric IE is minimal, if any Unusual Predisposing Factors Confirmed in children