This paper presents a non-randomized study comparing early surgery for such patients with severe mitral regurgitation (MR) versus ‘watchful waiting. When to advise surgery to an asymptomatic patient with severe valvular disease and preserved left ventricular (LV) function has been a subject of debate among clinicians since the advent of acceptable valve surgery. This is particularly true for severe regurgitant lesions of the aortic and mitral valves. Awaiting evidence of myocardial distress (e.g. LV dysfunction, pulmonary hypertension, atrial fibrillation) is fraught with the possibility of allowing irreparable LV damage with consequent increase in morbidity and mortality. As mitral valve repair (MVR) has become more feasible and as long-term results have proven generally favorable, the question of whether to refer such asymptomatic patients (pts) with apparently repairable MR to earlier surgery or to continue ‘watchful waiting’ has assumed even greater importance. This study emanates from the University of Ulsan in Seoul, Korea, where 477 consecutive pts were evaluated prospectively. Over a median of 1988 days, 286 patients were watched carefully while 161 underwent ‘early’ MVR. There were 2 repeat mitral surgeries in this latter group but no other endpoints (operative mortality, cardiac death, urgent admission for heart failure). In the conservatively managed group of 286, there were 12 cardiac deaths, 1 repeat mitral surgery, and 22 urgent hospital admissions for heart failure. The estimated actuarial 7 year cardiac mortality rate for the patients with early surgery was 0%, while it was 5±2% for those treated conventionally. There was no significant difference between the two groups in terms of age, gender, euroSCORE (operative risk evaluation) or LV ejection fraction. However, among the conventionally treated pts the independent predictors of late development of surgical indications or heart failure were baseline grade of pulmonary artery pressure (PAP) (hazard ratio 1.87) age (hazard ratio 1.02) and effective regurgitant orifice area (EROA) (hazard ratio 2.06). The baseline grade of PAP was based on peak velocity of TR by echocardiogram and even minimal or mild elevation was predictive of future events. The EROA was also derived by echocardiography. The authors conclude that even mild elevations in PAP and a larger EROA should warrant serious consideration of MVR in asymptomatic patients with apparently normal LV function and severe MR. Current American College of Cardiology/American Heart Association guidelines give surgical indication of class IIa for significant pulmonary hypertension (PAP>50mmHg) {1}. Further prospective randomized studies are needed to confirm the efficacy and value of early surgery.