Technique: The suitability of the pulmonary autograft for aortic valve replacement has to be studied by accurate measurement by echocardiogram of the aortic and pulmonary annuli. Size discrepancy of the pulmonary autograft annulus and the aortic annulus should not be more than 2mms. A transverse

aortotomy is done 'and aortic valve inspected. Once suitability for Ross procedure is determined, ascending aorta is transected. Aortic valve with aortic root and sinuses are removed leaving buttons of left and light coronary ostia. Pulmonary artery is transected proximal to its bifurcation. Incision is made on the anteiior part of right ventricular infundibulur well below the pulmonary artery annulus. Dissection on the infundibular septum has to be done carefully to avoid injury to the first septa1 branch of left anteiior descending coronary artery.

To a great extent, the success of the Ross operation depends on the successful completion of this step. The autograft is then removed and necessary trimming done. The proximal anatomises between pulmonary autograft and aoitic annulus is done with continuous prolene sutures. In children, some surgeons prefer absorbable suture when growth of pulmonary autograft is desired. Then the coronary buttons are sutured to appropriate sized holes made on the pulmonay autograft. After that, distal end of the autograft is anastoinosed to the remaining end of the transacted aorta. A pulmonary allograft (homograft) is then sutured to replace the pulmonary valve and the main pulmonary artery.