It's always hard to follow a presentation by Carl Backer. Today, we have heard several presentations about the problem of pulmonary insufficiency. We have been shown multiple images of dilated and poorly functioning right ventricles. The obvious conclusion is that these patients should undergo replacement of the pulmonary valve. I agree with Carl that operative morbidity and mortality for replacing the pulmonary valve is minimal, but we must also consider the outcomes in the long-term. Most physicians would agree that valvar replacement is indicated in a symptomatic patient with right heart failure and exercise intolerance. In order to win this debate, therefore, it will necessary to redirect and alter the question! The question I am going to consider is: “should we replace prophylactically the pulmonary valve in asymptomatic patients with pulmonary insufficiency and right ventricular dilation?