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The Ross procedure is an established method to treat aortic valve disease, offering excellent hemodynamic characteristics, growth potential, low risk of thromboembolism and no need for anticoagulation. Limitation of homograft quality and availability led to the use of different stentless xenografts. Long-term outcome and implications are yet to be addressed.Forty five adult patients (mean age 38.8 ± 9.6 years) with aortic valve stenosis and/or insufficiency, who underwent the Ross procedure between 1995 and 2002 were identified for long-term evaluation. Patients younger than 18 years, with previous heart surgery and endocarditis were excluded. Stentless xenografts were used in 22 cases (Group X) and homografts in 23 cases (Group H). After review of the patients' history, morbidity and mortality were analyzed and risk stratification was performed.Between groups, baseline characteristics and operative data did not differ significantly. Total follow-up was 621.0 patient-years and 98.8% complete. Overall freedom from reoperation at 15 years was 68.4 ± 10.6% in group X and 85. ± 7.9% in group H (p = 0.09), respectively. Freedom from aortic valve reoperation at 15 years was comparable (83.9 ± 8.5% in group X and 85.3 ± 7.9% in group H, p = 0.61), whereas freedom from pulmonary valve reoperation at 15 years was significantly lower in group X (78.9 ± 9.4% versus 100%, p = 0.02). Long-term survival at 15 years was 79.7 ± 9.3% in group X and 94.4 ± 5.4% in group H (p = 0.07), respectively.Stentless xenografts used as pulmonary valve substitute in the Ross procedure led to lower freedom from pulmonary valve reoperation compared with homografts. Additionally, there was a trend to inferior long-term survival with xenografts. Therefore, homografts should remain the preferred option for pulmonary valve replacement in the Ross procedure.