essentially the same; to replace a diseased aortic valve with the person's own pulmonary valve (autograft), and replace the person's own pulmonary valve with a pulmonary valve from a cadaver (homograft) or a stentless xenograft. It is an alternative to a mechanical valve replacement, particularly in children and young adults. It avoids the need for thinning the blood, has favourable blood flow dynamics and the valve grows as the person grows. The most common reason for performing the Ross procedure in children and young adults is for bicuspid aortic valve. Contra-indications It is not performed in Marfan syndrome, if pulmonary valve disease, or if immune problems like lupus. Other contraindications include severe coronary artery disease and severe mitral valve disease. Due to a higher chance of dysfunction of the autograft, it may not always be safe to perform in rheumatic valve disease, or if a dysplastic dilated aortic root. Risks/complications The procedure requires technical expertise, and risks converting a single-valve disease into double-valve disease. It may need re-operating on at a later date. Complications include endocarditis, degeneration of the valves, aortic dissection, haemorrhage and venous thromboembolism, among others. Technique Before the operation, preparations include transthoracic echocardiography and measurements of the ascending aorta and the pulmonary valve. Under general anaesthesia, the chest is cut open in the midline. The heart and aorta are exposed before the heart is temporarily stopped and its function taken over cardiopulmonary bypass. Subsequent steps include removing the diseased aortic valve and mobilizing the coronary arteries, followed by harvesting and preparing the person's own healthy pulmonary valve, before implanting it within the left ventricular outflow tract, the exit of the left side of the heart (where the aorta begins). Then the coronary artery is reimplanted, before the pulmonary homograft is implanted in the right ventricular outflow tract, the exit of the heart's right side (where the pulmonary artery begins). The pulmonary autograft is joined to the ascending aorta. Pulmonary valve replacement Cryopreserved pulmonary homografts were most often used for a long time until the introduction of decellularized homografts. Variations If the left sided outflow root needs to be enlarged to fit the pulmonary autograft, the procedure is called Ross-Konno. An alternative to a pulmonary homograft is the stentless xenograft roots such as the Freestyle Porcine Aortic Root by Medtronic. An external Dacron graft can be used to reinforce the pulmonary autograft. Recovery After the operation, good blood