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1,2,13 Several studies using propensity-scoring models have shown conflicting results with respect to the benefits of medical procedures,12,14-16 and the choice between surgery and medical therapy is not clear-cut. Previous observational studies evaluating the outcomes of medical procedures with those of medical therapy have been subject to the restrictions imposed by baseline distinctions between the treatment groupings and treatment-selection and survivor biases12,14-18; prospective, randomized trials may reduce these limitations. In this randomized trial, we hypothesized that the benefits of surgical treatment would be maximized by performing medical procedures within 48 hours after randomization, because the risk of embolism has been reported to be high during the first week after analysis particularly.4,6,19 The rate of embolism in the conventional-treatment group was similar compared to that reported in various other studies,6,11,12 and the rate of embolism in the early-surgery group was markedly reduced, as compared with conventional treatment, needlessly to say from our earlier observational study.12 Therefore, we suggest that early surgery is a valuable therapeutic substitute for prevent embolism.