Criteria for choosing the optimum time for operation in patients who have aortic regurgitation (AR) have changed in recent years, including a number of notable new components [1,2]. In the 1970s and 1980s, selecting patients for valvular surgery entailed waiting as long as possible until symptoms became substantial [3], which usually meant New York Heart Association (NYHA) class III symptoms that were not controllable with medical management. At that time, the primary surgical option was aortic valve replacement for which the perioperative mortality was high and postoperative problems with ‘‘prosthetic valve diseases’’ were substantial. In stable patients, clinicians watched for measurements of left ventricular (LV) size and function as the primary clinical indicators for surgical timing. In current medical practice, the process of selecting patients is different in a variety of ways. Improved diagnostic methods are available to understand changes in the structure of the aortic valve itself, often including the etiology and mechanism of the dysfunction. Acute cardiac imaging allows a better understanding of a patient’s aortic valve and allows better prediction of the likely future progression of the disease based on natural history studies. Improved quantitation of the severity of the AR is feasible using Doppler echocardiography and other methods. The effects of AR on cardiac function and the potential complications that occur with medical or surgical management can be anticipated. Operative mortality has declined remarkably. For isolated, uncomplicated aortic valve operations at Cleveland Clinic, in-hospital mortality decreased from 2.4% during 1980 to 1989 to 1.7% during 1990 to 1999 and to 1.2% during 2000 to 2005. Surgical options have improved, including more nonprosthetic options such as valve repair. Available prosthetic valves are more durable than in the past. In patients needing isolated primary aortic valve surgery, minimally invasive techniques [4] can be used, avoiding some the discomfort, bleeding, and other temporary disabilities resulting from a full midsternal thoracotomy. Newly developed percutaneous [5–7] and robotic [8] methods have already been used in limited numbers of patients, and their future role is hopeful. Accordingly, the threshold for valve surgery has been progressively reduced. It is now reasonable to do valve surgery for AR in some asymptomatic patients. The clinician must carefully consider each patient individually, including his or her current state of health and fitness, all noncardiology problems, and the available resources for medical treatment, surgery, and recovery. Decisions for surgery or medical management should be based on a comparison between the likely outcomes of immediate surgery and the natural history of the disease if surgery is delayed.