A severely dysfunctioning congenitally bicuspid aortic valve may require surgical treatment within the fourth decade of life. Among conventional options, the pulmonary autograft (PA) offers many theoretical advantages particularly for young patients, including potential for growth, hemodynamic performance, no need for anticoagulants and freedom from endocarditis. However the operation is more complex and longer, may interfere with coronary and right ventricular anatomy and function and may expose the patient to the downside of two valves at risk. Aim of this retrospective study was to evaluate the mid-term results achieved with the PA performed in adolescents and young adults with a bicuspid aortic valve. Between July 94 and June 98, 26 patients, 22 males and four females, with a mean age of 24+/-10 years (range, 11 to 38), underwent bicuspid aortic valve replacement with a pulmonary autograft (stenosis 2-8%; insufficiency 13-50%; combined 11-42%). Eight patients (31%) were in NYHA FC I, 17 (65%) in II, and 1 (4%) in III. Mean preoperative ejection fraction was 67+/-7%. Three patients (11.5%) had a past medical history of endocarditis (healed in all) and in two the PA was a re-do procedure. The PA was inserted as a subcoronary implant in one case (4%) and utilized as a root in the remaining 25 (96%). The right ventricular outflow tract was reconstructed with a cryopreserved pulmonary homograft conduit in all cases. Mean cardiopulmonary bypass and aortic crossclamp times were 204+/-50 min (range, 174 to 300) and 157+/-35 min (range, 133 to 193) respectively. No early or late deaths had occurred at a mean follow-up of 22.5 months (range, 5 to 47.5). The first patient in the series (4%) was reexplored for bleeding and needed transfusions. The subsequent routine use medical and surgical strategies resulted in no further need for postoperative reexploration, and successful containment of total postoperative blood loss (<350 ml/m2BSA). 2-D Echo evaluation of neo-aortic valve competence at 6 months, revealed no evidence of aortic valve regurgitation in 17 (65%), trivial regurgitation in seven (27%), mild in one (4%) and mild-to-moderate in one (4%). The latter patient (subcoronary implant PA) required reoperation. At six months, the mean degree of regression of left ventricular mass compared to pre-operative data, was 36% (333+/-94 to 212+/-60 gr, p<0.05). All patients are asymptomatic, in NYHA FC I, and enjoy normal social interaction. In conclusion, PA root implantation can be offered as a low-risk alternative to conventional prosthetic aortic valve replacement to adolescents and young adults with a bicuspid aortic valve. The routine achievement of blood loss containment has minimized the risk of transfusion thus contributing to expand the indication in young patients. Continued patients evaluation particularly with regard to evidence of neo-aortic valve degeneration, root dilatation and homograft dysfunction in the long term is warranted.