In asymptomatic patients with severe AR and normal LV systolic function at rest (LVEF >55%; Stage C1) and low surgical risk, aortic valve surgery may be considered when there is a progressive decline in LVEF on at least 3 serial studies to the low normal range (LVEF 55% to 60%) or a progressive increase in LV dilation into the severe range (LV end- diastolic dimension [LVEDD] 3: Harm B-NR In patients with isolated severe AR who have indications for SAVR and are candidates for surgery, TAVI should not be performed.29 32 Synopsis Most patients with indications for surgery for chronic severe AR require valve replacement with a mechani- cal or bioprosthetic valve (Figure 4). Preservation of the native aortic valve ( valve sparing ) may be pos- sible in selected patients with favorable valve anatomy who are undergoing surgical replacement of the aortic sinuses and/or ascending aorta.33 39 Although advanc- es are occurring in primary aortic valve repair,37,40 42 this approach is not yet generalizable, and durabil- ity is not known. Current recommendations for AVR related to severity of LV dilation are based on mea- surement of LV short-axis diameters. There are limited data demonstrating prognostic value of LV volume measurements in chronic AR using left ventriculogra- Normal limits for LV volumes have been determined, as have criteria for severe LV dilation, but these values differ between 2D echocardiography, 3D echocardiography, and there are insufficient data on the relationship between LV volumes and outcomes of patients with AR. This is an area in need of further investigation. 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. 