Advanced age and presence of ischemic heart disease increases mortality following aortic valve replacement (AVR). Over a four-year period, 123 predominantly elderly patients underwent AVR using the Toronto SPV. Despite advanced age (median 72 years) and high concomitant procedure rate (49%), the early mortality rate was low (0.8%). Mean (± SD) actuarial survival at 53 months was 78 ± 5.9%, with most patients in NYHA classes I and II. Serial Doppler echocardiography revealed excellent effective orifice areas with low transvalvular gradients (8.8 ± 4.3 mmHg) for all valve sizes. Left ventricular end-systolic dimensions and fractional shortening improved significantly during the study period. We conclude that the Toronto SPV is an appropriate choice for patients who are elderly and/or require concomitant procedures. In addition to the low operative mortality and excellent functional outcome, the superior hemodynamic profile resulted in left ventricular function improvement.