The article presents a clinical case of late cardiovascular syphilis in a patient with rapid progression of aortic insufficiency and death in the presence of conservative specific therapy. An analysis of the medical history of this patient pushes us to think about two very important problems which physician should recognize and solve. The first of these is the diagnosis. All patients with cardiovascular pathology should be screened for syphilis. If the screening test is positive (and there should be done twice during inpatient examination — RPR (MRP) and ElISA summ.), An extensive serological examination is performed and, assessing the nature of the cardiovascular pathology, the diagnosis of cardiovascular syphilis is established or rejected. The second problem of the attending physician after establishing a diagnosis of late cardiovascular syphilis is an unmistakable choice of tactics for the management of a patient who has indications for both specific and surgical treatment. This issue should be decided jointly by a cardiac surgeon and a dermatovenerologist taking into account: 1) a significant number of factors substantiated by a significant rate of development of heart failure with the syphilitic nature of damage to the cardiovascular system; 2) the duration of conservative specific therapy, which according to the standard scheme is 3 months and 1 week; 3) the possibility of death, including during specific therapy.