It is axiomatic that symptomatic aortic stenosis is a malignant condition for which the only effective treatment is valve replacement.1Of course, several factors other than the state of the valve have to be considered before surgery is recommended to a patient. Important among these are the presence and severity of other disease, and the estimated risks of perioperative death or serious complications. Decision making is often difficult in the case of elderly patients—arbitrarily taken to mean those aged 70 and older—in whom weighing the risks and benefits of surgery may be a complex matter. How do the studies in this issue2-4 contribute to the evidence base on which our advice should stand?

Bouma and colleagues from the Netherlands2 report an observational study of 205 patients aged 70 and older (33% ⩾ 80 years) who were identified by Doppler echocardiography as having an aortic valve area of < 1 cm² or a maximum aortic valve gradient > 50 mm Hg. Patients with severe comorbidity, or who had declined valve surgery, were excluded. They investigated the differences in clinical and echocardiographic characteristics as well as outcome between patients initially managed medically and those who had valve replacement. They draw two conclusions: elderly patients with symptomatic aortic stenosis are often denied surgery; and valve replacement in this age group improves survival, especially if left ventricular contraction is impaired.

Their second point is uncontroversial. Aortic valve replacement can extend survival in patients of all ages with symptomatic aortic stenosis; for the very old (aged …