The authors reviewed their experience with combined aortic valve replacement and coronary artery bypass grafting using a standardized cold cardioplegic technique for intraoperative myocardial protection in 54 consecutive patients during a 5-year interval ending in May 1982. Calcific aortic stenosis was the most common indication for aortic valve replacement. Thirty-seven patients (69%) had greater than 50-60% stenoses in at least two of the three major coronary arterial systems. No patient with combined aortic valvular and coronary artery disease had only valve replacement during the study interval, and no patient was refused operation. The mean number of arteries grafted was 2.4. There was one hospital death (1.9%), and one patient (1.9%) had electrocardiographic evidence for perioperative myocardial infarction. One additional patient required postoperative intra-aortic balloon pumping. There have been four late deaths in the followup period extending to 65 months. Survival at 3 years for the entire group was 87%, for the patients with aortic stenosis was 95%, and for the patients with aortic regurgitation or mixed lesions was 65%. There were no cardiac-related deaths among the patients with aortic stenosis and one non-fatal myocardial infarction in the follow-up period. The results with this technique of intraoperative myocardial protection are superior to those reported with previously employed methods (coronary perfusion, hypothermic ischemic arrest) and indicate that coronary artery bypass grafting should be performed in all patients with coexisting aortic valvular and coronary artery disease who require valve replacement. A substantial benefit (increased survival, decreased late myocardial infarction) may exist for the subgroup of patients with aortic stenosis.