Background. Pulmonary autograft replacement of the aortic valve is accepted in the young, those with an active life style, and those who are not candidates for anticoagulation. However, concern remains about autograft or homograft valve failure. Methods. One hundred ninety-five operative survivors of the Ross operation (August 1986 through December 1995) were reviewed for operative pathology and factors associated with reoperation or valve dysfunction. Results. Actuarial freedom from reoperation (autograft or homograft) is 89% ± 3% at 5 years, 92% ± 3% for the autograft alone. Early autograft valve failures ( Conclusions. Pulmonary autograft replacement of the aortic valve has a low incidence of reoperation for autograft dysfunction or homograft obstruction. Autograft dysfunction can be corrected by autograft repair in patients with central insufficiency and aortic annular dilatation.