Selection of elderly patients for heart failure surgery is based on careful evaluation of the risk/benefit ratio. The global risk profile and the single variable impact can be easily quantified by using validated scoring systems. Both age and left ventricular dysfunction are independent determinants of mortality; nevertheless they cannot be considered absolute contraindications for surgery. Risk of mortality is related to age in a linear fashion; consequently an age cut-off value for excluding patients from surgery cannot be defined. The presence of other risk factors and the resulting global risk profile have to be considered to identify suitable patients for surgery. Elderly patients undergoing mitral valve surgery need a particularly accurate assessment since mitral procedures are associated with an increased short- and medium-term mortality; hemodynamic instability, renal failure, advanced heart failure and concomitant coronary surgery might contraindicate surgery. A significant improvement in the functional status and quality of life justifies surgical treatment of elderly patients when the predicted risk is reasonable although benefits in terms of increased survival have not been clearly confirmed yet.