Other markers of LV dysfunction and re- modeling, such as global longitudinal strain and circu- likewise require additional clinical outcome studies. Recommendation-Specific Supportive Text 1. Symptoms are an important indication for AVR in patients with chronic severe AR, and the most important aspect of the clinical evaluation is tak- ing a careful, detailed history to elicit symptoms or diminution of exercise capacity. Patients with chronic severe AR who develop symptoms have a high risk of death if AVR is not performed,52 and survival and functional status after AVR are related to the severity of preoperative symptoms, assessed either subjectively or objectively with Even among symptomatic patients with a severe reduction in LVEF (<35%), AVR results in improved survival rate.5 7 2. LV systolic function is an important determi- nant of survival and functional status after Outcomes are optimal when surgery is performed before LVEF decreases In asymptomatic patients with LV systolic dysfunction, postoperative out- comes are better if AVR is performed before onset of symptoms.53 3. Patients with chronic severe AR may be referred for other types of cardiac surgery, such as CABG, mitral valve surgery, or surgery for correction of dilation of the aortic root or ascending aorta. In these patients, AVR will prevent both the hemo- dynamic consequences of persistent AR during the perioperative period and the possible need for a second cardiac operation in the near future. Patients undergoing surgical repair or replacement of the aortic root or ascending aorta may be can- didates for aortic valve sparing procedures.33 39 4. LVESD in patients with chronic AR reflects both the severity of the LV volume overload and the degree of LV systolic shortening.54,62 An elevated LVESD often reflects LV systolic dysfunction with a depressed LVEF. 