The increased life expectancy of the Western population in the last decades , associated with the improvements in surgical standards and postoperative care, has progressively expanded the age criteria of operability in cardiac surgery . As a consequence, the number of elderly patients undergoing heart valve replacement has been increasing, as well as their long-term survival. In particular it has been rising the number of elderly requiring AVR for severe calcific aortic valve stenosis, which is a tipical disease of the older age.
The growing number of elderly referring to cardiac surgical procedures has increased the attention on the outcomes in this subset of patients and on the prediction of long term survival.
When coronary artery obstructive disease is associated to severe aortic valve calcific stenosis in the elderly patients, CABG has to be combined to AVR.
Many clinical series investigating determinants of early mortality following AVR, identified associated CABG as independent predictor [11, 12].
The 4th European Association for Cardiothoracic Surgery Adult Cardiac Surgery 2010 database reports that overall mortality for isolated valve surgery is 3.7% while for CABG combined with valve procedures it increases to 6.2% .
Also in our series the association of CABG to AVR demonstrated to increase hospital mortality (15.2% vs 7.8%) and univariate analysis revealed CABG as a predictor of early death.
At the same time CABG associated to AVR improves long term survival with acceptable morbidity and mortality in elderly patients .
This data is confirmed by several reports: on the arena of long term survival, Akins et al. Reported the survival of patient following CABG is essentially equivalent to that of age and gender matched cohorts from the general population up to 5 years after surgery . Sergeant and associated demonstrated that the actuarial survival of elderly coronary artery by-pass patients came actually be better than that predicted for the general population out to 10 years, whereas survival of the young coronary by-pass patients is poorer than a comparable cohort from the general population .
Findings of our study confirmed that long term mortality and morbidity are not significantly different when CABG is associated to AVR in elderly patients suffering of severe calcified aortic valve stenosis and obstructive coronary disease.
In order to extend the investigation to long term quality of life, the SF-36 test was applied in both groups of patients. Group A and Group B showed similar scores in QOL that resulted better of age and gender matched population. The increased life expectancy results in a growing necessity to maintain maximum functioning and independent lifestyle. Health-related QOL is a multidimensional concept based on the patient's perception of his or her health and integrates not only physical functioning but also psychologic status and social dimensions. Standardized questionnaires, especially those self-completed by patients, are a practical, efficacious, and inexpensive method of collecting data. There is a growing interest in the use of health status to evaluate clinical strategies, and because improvement in QOL is considered to be one of the principal goals of valve surgery , methods of QOL assessment are increasingly adopted in the clinical research in this field. From reports on postoperative QOL, patients deciding among treatment options may value information about the change in QOL that they can expect after valve surgery. Therefore, QOL needs to be assessed in large and well-defined patient subsets, and it is particularly important to evaluate QOL in elderly patients, who have a higher prevalence of comorbidity, a more severe surgical stress, and a higher risk of postoperative complications, all factors that may hinder improvement in QOL. Although numerous methods exist for evaluating QOL of patients , the validated SF-36 questionnaire  is comprehensive yet concise, can be completed in 10 to 15 minutes, and can be administered in person, by phone, or by mail, even in elderly patients .
Investigators focusing on long-term outcomes after AVR in octogenarians have reported a positive impact on QOL . Sundt and colleagues described postoperative SF-36 scores in AVR patients aged older than 80 years that were comparable with those of the general elderly population . In the present study, we obtained in seven of the eight domains of the test significantly higher scores than the mean general Italian population matched for age and sex.
When interpreting this result, it should be considered that more than 70% of the patients in our study population were in NYHA functional class III to IV before the operation, so a high percentage of our patients experienced, for a various period of time, a moderate to severe limitation to their daily activity. Symptom relief and the return to previous lifestyle can probably increase the perception of a patient's own health status. Similarly, the Italian general population scores were lower than in our study population because the healthy elderly are prone to compare their current physical and psychologic performances with their youth, with a perceived difference caused by the effects of the aging process itself. Other authors in series of AVR  found similar differences between the previously operated on elderly and the age-matched control population, in particular for what concerns the social functioning and emotional domains.
Associated CABG determines an increase of hospital mortality in the elderly undergoing aortic valve replacement; at the same time survivors did not show differences in long-term outcome and quality of life according to the presence of associated CABG.