Between August and October 1994, valve-sparing annulo-aortic grafting (AAG; reported by David in 1992) was performed in four patients with annuloaortic ectasia (AAE). There were two women and two men, with a mean age of 54.0 +/- 12.2 years. The maximum diameter of the ascending aorta (AS.AO), the leaflet length (LL), the diameter of the annulus (D.Annulus), the size of the graft used (Graft), the grade of AR and the postoperative transvalvular pressure gradient (PG) are shown in the following table. The expected diameter of the annulus was calculated as four-thirds of the leaflet length.The aortic valve was placed inside the graft and mattress sutures were passed from inside to outside the left ventricular outflow tract below the aortic valve and through the graft. In the third patient, the annulus shrank to 15mm by tying these sutures intensively, and additional plication of the right coronary cusp was required because the prolapse was magnified by the narrowing of the annulus. In the last patient, these sutures were tied positioning bogie of appropriate size inside the annulus. All the patients returned to NYHA I or II, and all the AR were well controlled except in the third patient. Although a valve-sparing annulo-aortic grafting is a useful procedure for the patients with AAE associated with AR, more attention should be paid to preventing a narrowing of the aortic annulus.