Until today, no perfect valve substitute has been developed. Some essential requirements for a perfect valve substitute are proposed in Table 1. Regarding the aortic valve, the Ross procedure (pulmonary autograft operation) is closer to this ideal than any other substitute in many ways. For this reason, it was enthusiastically adopted by many surgeons after it became widely known in the late 1980s and was technically simplified by Stelzer and Elkins [27] (total root replacment, Fig. 1). In recent years, however, several groups report high reoperation rates and a worrysome tendency for the development of neoaortic regurgitation and/or ascending aortic aneurysms [7, 10, 16, 18, 20, 29]. A recent systematic review concluded that durability limitations become apparent by the end of the first postoperative decade, in particular in younger patients [28], and it was asked whether the ross procedure is a Trojan horse [15]. As a result of these newer data, many centers appear to have stopped performing the Ross procedure. Table 1. Proposed criteria of an ideal valve substitute Fig. 1. Schematic drawing of the Ross procedure. The diseased aortic valve is resected (1). Then, the autologous pulmonary root including the valve is harvested from the right ventricular outflow tract (RVOT) (2). The autologous pulmonary valve can be implanted into the aortic position using different techniques Full root replacement: this technique was popularized by Stelzer and Elkins and is the technique most often used worldwide. The autologous pulmonary root is implanted in the aortic position (3). With this technique, reimplantation of the coronary arteries into the neoaortic root is necessary, but the geometry of the pulmonary root can be easily preserved in its new position Subcoronary implantation: this is the technique originally described by Ross and still preferred by the Luebeck group. The autologous pulmonary valve is implanted into the aortic root in a subcoronary position (4) Cylinder inclusion technique: this technique combines features from the other two techniques. It is technically the most demanding and is only rarely used (5) To complete the operation, the defect in the RVOT needs to be reconstructed, usually by implantation of a pulmonary allograft root (6)