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. If LVEF is normal, an increased LVESD indicates a significant degree of LV remod- eling and is associated with subsequent develop- ment of symptoms and/or LV systolic dysfunction and an increased mortality rate after AVR.17,20,21 Most studies have used unadjusted LVESD, but indexing for body size is important, particularly in women or small patients.13,19,52 Recent data indi- cate that the LVESD index threshold for optimal postoperative survival may be even smaller than but more outcome data, and ide- ally an RCT, of earlier intervention are needed. CLINICAL STATEMENTS AND GUIDELINES LV volumes may be a more sensitive predictor of cardiac events than LVESD index in asymptomatic but more data are needed to deter- mine the threshold values of LV systolic volume that best predict postoperative outcomes. 5. In patients with moderate AR who are undergo- ing other forms of cardiac surgery, such as CABG, mitral valve surgery, or replacement of the ascend- ing aorta, the decision to intervene on the aortic valve concurrently includes consideration of several factors, including aortic valve anatomy, aortic root size and shape, regurgitant severity, other comor- bidities, and patients preferences and values. Patients undergoing surgical repair or replacement of the aortic root or ascending aorta may be candi- dates for a valve-sparing procedure.33 39 6. 