This is a case of an athletic 35-year-old patient who presented to his primary care physician complaining of frequent episodes of chest pain, palpitations, and syncope, which interferes with his daily life activities. An echocardiogram demonstrated critical aortic stenosis with an aortic valve (AV) maximum velocity of 4.95 m/s (normal < 2 m/s) and an AV area of 0.8cm² (normal 3-4cm²). Cardiac MRA showed a heavily calcified bicuspid aortic valve. After a brief discussion with the patient regarding his options, given his age and physical activity level, we thought that he would benefit from a Ross procedure providing him with an anticoagulation free life and a highly durable valve. During surgical exposure, the aortic valve appeared heavily calcified. The valve was completely resected. Enucleation of the pulmonary valve (PV) from the right ventricular outflow tract (RVOT) begins with an incision in the infundibular area, 1.5 cm below the PV. This incision is continued in a curvilinear fashion which is made the same distance from the valve as done posteriorly so its symmetrical circumferentially. Plane of dissection is above the first septal perforator and the other troublesome venous plexuses that are posterior to the PV. Caution must be exercised while dissecting to avoid injuries of the left main coronary or the left anterior descending arteries. Once the autograft is excised, it is key to obtain the correct sized Hemashield Dacron graft. The inclusion or wrapping graft is truly sized or upsized slightly (2-3mm) to the PV autograft dimensions to provide proper restriction of progressive dilation. The autograft is attached at the annular level with a horizontal mattress suture. At the distal end of the autograft, we place stitches initially at each of the commissures to make it symmetrical, we then use a running prolene suture to secure the distal end. We check for composite graft competence. The patient is 2 years postop. The most recent echo showed an AV maximum velocity of 1.16 m/s and an AVA of 3.86 cm². The patient has been symptom-free since his operation and returned to his normal workout schedule.

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