Fifty-four consecutive patients underwent aortic valve replacement with a pulmonary autograft (Ross operation) over an 18-month period. It was inserted as an intra-aortic cylinder in 13 patients and as a total aortic root replacement in 41; unwrapped in 16, partially wrapped with autologous pericardium in 12 and completely wrapped with bovine pericardium in 13. There were two cardiac deaths, one death from mediastinitis, and two early reoperations to replace an incompetent autograft. Comparison of postoperative echocardiographic data showed a higher incidence of moderate and severe autograft incompetence in the intra-aortic cylinder group and also in the subset without previous operation which had a total root replacement without a complete wrap. Autograft function was best in the group which received a total root replacement with a complete wrap and in those with previous cardiac surgery who received an unwrapped autograft. This preliminary information with short follow up supports the use of complete wrapping of the autograft when it is used as a total root replacement particularly in older patients without previous cardiac surgery in whom future autograft growth is not desirable.