Since age is no longer considered an additional risk factor for cardiac surgery, the epidemiology of valve disease in the elderly at present may be estimated from the surgical pathology evaluation of valve specimens which are resected at the time of valve replacement. In the time interval 1991-1993, 500 patients underwent native cardiac valve replacement or repair at our University, with a total of 549 valves available for gross and histological examination. Single valve surgery was performed in 451 patients (300 aortic, 148 mitral, 3 tricuspid), and double valve replacement in 49 (47 mitral-aortic, 1 aorto-tricuspid and 1 mitral-tricuspid). Two hundred and eighteen patients (44%) were older than 65 years; the mean age was 70.4 +/- 4.3 years, and the male to female ratio was 0.9 to 1. Two-thirds of the interventions in the elderly group were aortic operations. However, regardless of the age group, 50 and 60% of the cases with respectively aortic and mitral valve disease were due to rheumatic disease. Age-related degenerative valve diseases were prominent; senile dystrophic calcification with aortic stenosis mostly in the elderly, anuloaortic ectasia with aortic incompetence mostly in adults, and floppy valve with mitral incompetence in both age groups. Bicuspid aortic valve, a congenital anomaly which is silent until adulthood, accounted for both aortic stenosis and stenoincompetence by dystrophic calcification, and pure aortic incompetence by endocarditis or anuloaortic ectasia. Our findings suggest that although age-related degenerative valve diseases are increasing, rheumatic disease still remains the leading cause of valve dysfunction in our country even in the elderly. These data may have an impact on prevention strategies and health-care costs. However, it has to be pointed out that the high prevalence of rheumatic disease is a feature of this particular study but is different from the findings of other studies around the world.