As mechanical complications after myocardial infarction in the elderly, we described the therapeutic strategies for postinfarction ventricular septal perforation (PVSP), ischemic cardiomyopathy (ICM), and ischemic mitral regurgitation (IMR). To improve operative results for PVSP in the elderly, it is important to maintain hemodynamics by cardiac support device such as intraaortic balloon pumping, and to perform prompt surgical intervention before cardiogenic shock and multiple organ failure. Infarct exclusion technique is a standard surgery for PVSP. Both ICM and IMR are common disease caused by severe cardiac ischemia and mitral valve (MV) function is related to left ventricular (LV) geometry. We consider total MV-LV geometrical repair by LV restoration surgery, MV repair, and coronary revascularization is essential to improve morphological abnormality in LV and MV even in the elderly. To maximize LV function, septal anterior ventricular exclusion (SAVE) technique for antero-septal myocardial ischemia, apex-sparing Batista operation for lateral ischemia, and undersized mitral annuluoplasty to improve LV sphericity are procedures of choice. However, it is still difficult to save elderly patients with very low cardiac function. Novel treatments such as regenerative medicine by angiogenic cytokines and/or cell transplantation, and advanced medical treatments are waited for this high-risk group.