Objective: We analyzed the long-term morbidity and mortality of our experience with combined mitral-aortic surgery, as well as their determinants. Methods: Among 2109 consecutive patients undergoing valve operations, 200 had mitral-aortic valve procedures with at least implantation of a mechanical prosthesis: 163 of 200 (81.5%) patients had double valve replacement and 37 of 200 (18.5%) had mitral valve repair and aortic valve replacement. All mechanical valves were bileaflet prostheses. Preoperatively, 171 of 200 (85.5%) patients were in New York Heart Association class III-IV. Event-free survivals were determined by means of the Kaplan-Meier method and determinants of survivals with the Cox proportional hazards model ( p < 0.05) entering 39 preoperative and perioperative factors. Follow-up was complete for 96% of the patients (192/200). Results: Overall survivals at 5, 10, and 15 years were 88.5% ± 0.55%, 73.5% ± 4%, and 53.3% ± 8.9%, and rates of freedom from valve-related mortality were 92.9% ± 1.5%, 85.8% ± 3.5%, and 85.8% ± 3.5%. The rates of freedom from permanent valve-related impairment were 91.5% ± 1.7%, 85.4% ± 3.5%, and 79.3% ± 6.7%, and those from all valve-related mortality and morbidity were 74.1% ± 2.3%, 53.8% ± 5%, and 49% ± 5.6%. At last follow-up, 90% (139/154) of the survivors were in New York Heart Association class I-II. Left ventricular ejection fraction less than 50%, age older than 70 years, and preoperative ventricular arrhythmias were independent risk factors for valve-related late deaths. Diabetes, ejection fraction less than 50%, and coronary artery disease were independent determinants of all valve-related events. Conclusions: Functional results of survivors of combined mitral-aortic surgery are excellent. However long-term valve-related morbidity and mortality are substantial. In the patient population studied, the predictors are determined by patient-related factors, mainly myocardial factors, but not by valve-related factors. (J Thorac Cardiovasc Surg 1998;115:1298-309)