The mitro-aortic disease in high-risk patients is a challenge for the cardiac surgeon because minimally invasive techniques are difficult to apply. We report the first case in the literature of a 78-year-old woman affected by severe rheumatic steno-insufficiency of aortic and mitral valves at high surgical risk. The patient was successfully treated by mitral valve replacement with a biological prosthesis and concomitant aortic valve replacement with a sutureless prosthesis.