Dear Sir,

We thank Professor Rubay for his comments. We agree that the elegant and detailed study, incorporating analysis of wall-stress, performed by Professor Rubay and his colleagues examines the determinants of functional recovery following the Ross procedure.

The aim of our study, however, was to provide guidance, based on routinely measured left ventricular dimensions, for determining the optimal timing of elective surgery. While the study of Professor Rubay and his colleagues noted that, as a group, patients with poorer postoperative ventricular function had larger preoperative left ventricular enddiastolic Z scores, our own data demonstrated that there appears to be a threshold, namely above 3 to 4 Z-scores, above which functional recovery, in the individual, becomes less likely. Taken together, we believe these two studies help to refine decision-making in this difficult group of patients.