39 patients in the aortic valve replacement group and 56 patients in the control group. One- and 4-year survival rates were markedly improved in patients in the aortic valve replacement group (82% and 78%) compared with patients in the control group (41% and 15%; P ! .0001). By mul- tivariable analysis, the main predictor of improved survival was aortic valve replacement [74]. Perio- perative outcomes and long-term results were also evaluated in a group of 132 consecutive patients who had impaired left ventricular systolic function (!40%) undergoing aortic valve replacement with or without concomitant CABG between 1990 and 2003. Patients who had other valve pathology were excluded. Preoperatively, 82% of the patients were in NYHA III or IV. Sixty patients (45%) un- derwent aortic valve replacement for severe aortic stenosis, whereas 72 (55%) had aortic insufficiency. In the aortic stenosis group, the mean left ventricu- lar ejection fraction and aortic valve area were 26 Æ 4% and 0.8 Æ 0.4 cm 2 , respectively. All patients had a mean LVEF of 27 Æ 6% and a mean left ventricular end-systolic diameter of 52 Æ 9 mm. Fifty-seven (43%) required concomi- tant CABG. LVEF increased to 29 Æ 10% and 34 Æ 12% after 6 months in the aortic stenosis and aortic insufficiency groups, respectively. The mean follow-up period was 6.1 years with no differ- ences for both groups with respect to either perio- perative or long-term outcomes. Overall survival was 96%, 79%, and 55% at 1, 5, and 10 years, re- spectively [75]. Overall, these results suggests that both aortic valve replacement for patients who have low gradient aortic stenosis and aortic regur- gitation confines a greater survival benefit than that of heart transplantation, although special care should be taken in the selection of prosthetic valve used for replacement. The ACC/AHA guidelines for evaluation of patients who have aortic valve dis- ease states that aortic valve replacement is indi- cated for symptomatic patients who have severe aortic regurgitation irrespective of left ventricular systolic function as well as in patients who have se- vere aortic stenosis and left ventricular systolic dys- function, which is defined as ejection fraction less than 50% [72]. Left ventricular geometry restoration Prospective randomized comparison is being conducted by the STICH trial, which evaluates whether surgical ventricular shape restoration in combination with CABG improve outcome com- pared with coronary revascularization alone and medical therapy alone in one of the study arms [56]. The safety and efficacy of surgical anterior ventricular endocardial restoration, which in- cludes the exclusion of noncontracting segments in the dilated remodeled ventricle after anterior myocardial infarction was evaluated in an obser- vational effort of 11 centers. From January 1998 to July 1999, 439 patients underwent the proce- dure and were followed for 18 months. Concomi- tant with safety and efficacy of surgical anterior ventricular endocardial restoration, coronary artery bypass grafting was done in 89% of the pa- tients, mitral valve repair in 22%, and replace- ment in 4%. Hospital mortality was 6.6%. Postoperatively, ejection fraction increased from 29 Æ 10.4 to 39 Æ 12.4%, and left ventricular end-systolic volume index decreased from 109 Æ 71 to 69 Æ 42 mL/m 2 (P ! .005). At 18 months, survival was 89.2% (84% in the overall group and 88% among the 421 patients who had coronary artery bypass grafting or mitral valve repair) [76]. The international Reconstruc- tive Endoventricular Surgery returning Torsion Original Radius Elliptical shape to the left ven- tricle (RESTORE) group evaluated surgical ven- tricular restoration in a registry of 1198 postinfarction patients between 1998 and 2003. Concomitant procedures included CABG in 95%, mitral valve repair in 22%, and mitral valve replacement in 1%. Overall 30-day mortality was 5.3% (8.7% with mitral repair versus 4.0% with- out repair, P ! .001). Perioperative mechanical support was uncommon (!9%). Left ventricular ejection fraction increased from 29.6 Æ 11.0% to 39.5 Æ 12.3% (P ! .001), and left ventricular end systolic volume index decreased from 80.4 Æ 51.4 mL/m 2 to 56.6 Æ 34.3 mL/m 2 (P ! .001). Overall 5-year survival was 68.6 Æ 2.8%. In this study, and ejection fraction 30% or less, left ventricular end-systolic volume 80 mL/m 2 or greater, advanced NYHA functional class, and age equal or greater than 75 years as risk factors for death. Five-year freedom from hospital read- mission for CHF was 78%. Preoperatively, 67% of patients were class III or IV, and postopera- tively 85% were class I or II. Based on these data, the authors concluded that surgical ventric- ular restoration improves ventricular function and is highly effective therapy in the treatment of ischemic cardiomyopathy with excellent 5- year outcome [76]. The results of the STICH trial will probably solve the real role of surgical resto- ration therapy compared with conventional approaches. 330 CADEIRAS et al . patients in the aortic valve replacement group and 56 patients in the control group. One- and 4-year survival rates were markedly improved in patients in the aortic valve replacement group (82% and 78 %). restoration, which in- cludes the exclusion of noncontracting segments in the dilated remodeled ventricle after anterior myocardial infarction was evaluated in an obser- vational effort of 11 centers artery bypass grafting or mitral valve repair) [76 ]. The international Reconstruc- tive Endoventricular Surgery returning Torsion Original Radius Elliptical shape to the left ven- tricle (RESTORE)