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Background: Aortic valve regurgitation (AR) in the paediatric population has increased in recent years because of the expanded use of new surgical and hemodynamic procedures. Unlike adult patients, few predictors for the need of operation have been proposed in young asymptomatic patients with AR. Young patients with congenital isolated severe AR may offer the unique clinical opportunity to study the effect of pure chronic volume overload on left ventricular (LV) function.Study aim: to assess the clinical significance of preoperative echocardiographic parameters as a predictor of surgery in asymptomatic young patients with chronic AR.Methods and results: In 25 asymptomatic patients (mean age, 12 years; range 3- 16 yrs) with isolated chronic, moderate- to- severe AR, and normal ejection fraction (EF) (>55%) we performed standard and speckle tracking echocardiography. Patients were followed for a mean period of 3 years (range 3-6 years). Surgical timing was defined according to guidelines (ESC 2007). During the follow-up period 9 patients underwent surgical repair. Comparing baseline characteristics of surgical patients with the remaining 16 patients, surgical patients showed a significantly increased mass/height 2.7 (61±12 vs 48±9 g\m 2.7, p=0.045), and a reduced average LV longitudinal strain (-17.7±4.2 vs -22.9±2.9%, p=0.013). Conversely, LV diameters (even after BSA correction), E\Em, and EF were comparable between groups. Using ROC curve analysis, averaged LV longitudinal strain (cut-off: >-19.5%; 75% sensitivity and 93% specificity, AUC: 0.875) was indicated as a good predictor of surgery.Conclusions: Baseline average LV longitudinal strain is a good predictor for the need of surgery in young patients with severe congenital AR despite the presence of a normal EF.