A best evidence topic in cardiac surgery was written, according to a structured protocol. The question addressed was: in young patients with rheumatic aortic regurgitation compared to non-rheumatics is a Ross operation associated with increased incidence of autograft failure? The pulmonary autograft with its inherent advantages of viable autologous transplant, central laminar flow, freedom from prosthetic valve complications, side effects of anticoagulation, and growth potential is considered a well-accepted option for aortic valve replacement in young patients. However, the use of a pulmonary autograft in young patients with rheumatic aortic valve disease is controversial. We analyse existing evidence to determine the suitability of the pulmonary autograft as a substitute for the diseased aortic valve in patients with rheumatic disease. Altogether 901 papers were found using the reported search terms, from which eight represented the best evidence to answer the clinical question. In addition, a meta-analysis also superficially addressed this issue. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. All eight publications were from two institutions with one reporting outcomes for a Ross operation vs. mechanical valve implantation and two compared results of the Ross operation in rheumatic vs. non-rheumatic aortic valve disease. We conclude that the current available evidence suggests that pulmonary autograft is susceptible to rheumatic involvement. Use of pulmonary autograft in young patients (<30 years) with rheumatic aortic regurgitation and concomitant mitral regurgitation requires a cautious approach as there is an impaired autograft durability in this subgroup of patients.