Aortic valve replacement with a pulmonary autograft was performed on 241 patients between June 1967 and October 1986 at National Heart Hospital, Guy's Hospital, Middlesex Hospital, Harley Street Clinic, and Italian Hospital in London by one of the authors (D.N.R.). The longest follow-up is 18 years 7 months, and the cumulative total follow-up is 1130 patient-years (pt-yr). The overall 30-day mortality rate is 6.6% (16 patients), with no deaths after 1976, and the late mortality rate is 1.7%/pt-yr (19 patients). The actuarial survival rate is 57.3% +/- 9.6% at 19 years. No anticoagulation has been used and there have been no thromboembolic episodes. The incidence of bacterial endocarditis is 1.2%/pt-yr (14 patients), and its actuarial event-free rate is 74.2% +/- 8.1% at 19 years. Reoperation because of failure of the pulmonary autograft was performed on 36 patients, 27 of whom needed valve replacement. The incidence of pulmonary autograft replacement is 2.5%/pt-yr, and its actuarial event-free rate is 48.5% +/- 13.7% at 19 years. For reconstruction of the right ventricular outflow tract, 186 aortic homografts, 26 pulmonary homografts, 16 autologous fascia lata valved conduits, 7 autologous pericardial conduits with or without a valve, and 6 xenograft valved Dacron conduits were used. Thirty-one patients were reoperated on, mostly because of degeneration of this material. Pulmonary rather than aortic homografts are now favored for reconstruction of the right ventricular outflow tract Because of its satisfactory long-term result without the need for anticoagulation, as well as its safety as an established surgical procedure, this operation can be recommended to a wider range of patients.