OBJECTIVE--To assess the risk of aortic valve replacement and long-term follow-up in elderly patients with dominant aortic stenosis. DESIGN--Retrospective analysis of patients who had aortic valve replacement over a 10 year period and were routinely seen in an outpatient clinic. SETTING--University hospital. PATIENTS--93 patients aged > or = 60 and 47 patients > or = 70 years with symptomatic aortic stenosis undergoing aortic valve replacement. MAIN OUTCOME MEASURES--Early and late mortality in different age groups. Influence of preoperative signs and symptoms on overall outcome. RESULTS--The proportion of patients older than 70 years increased from 11% in 1978 to 54% in 1986. Perioperative mortality was 3.6% and mortality after 2 and 5 years was 9% and 13% respectively. Survival was similar (85% and 83%, respectively) in patients aged 60-69 years (group 1, n = 93, mean age 64.5 (2.7) and patients aged > or = 70 years (group 2, n = 47, mean age 72.6 (2.5)). Additional coronary artery disease and coronary bypass grafting did not significantly affect survival. The cardiothoracic ratio was inversely related to survival (Cox regression, p < 0.05). Preoperative symptoms (syncope, angina pectoris, and dyspnoea) were similar in both patient groups. After a mean (SD) follow up of 51 (33) months 96% of surviving patients were in NYHA functional class I or II with no difference between the two age groups. Similarly, the cardiothoracic ratio and Sokolow index decreased to near normal values in both age groups. CONCLUSION--The risk of aortic valve replacement in patients with dominant aortic stenosis is low and not significantly influenced by age. Therefore replacement may be performed without increased risk in elderly patients and with a good long-term outcome.