OBJECTIVE The Ross-Konno procedure is a last resort for patients with complex multilevel left ventricular outflow tract obstruction (LVOTO) often having other cardiovascular anomalies. It is typically preceded by multiple surgeries. Literature is scarce on long-term follow-up series. Therefore, we have reviewed our 20-year experience with this procedure in order to provide insights in patients' outcomes and to optimize patient selection. METHODS Between January 1995 and December 2014, 48 patients underwent the Ross-Konno procedure. The median age at operation was 12.8 months (range, 11 days to 31 years). Twenty-two (46%) patients were under 1 year of age. Forty-four (92%) patients had undergone a total of 82 previous procedures. Eleven (23%) patients had concomitant surgery, predominantly mitral valve (n = 5) and aortic arch surgery (n = 5). RESULTS The median follow-up time was 4.3 years (range, 0-20 years). There were 6 (12.5%) early deaths and 4 (8.3%) late deaths. Estimated overall survival at 5, 10 and 15 years was 83, 79 and 70%, respectively. Poor LV function was a risk factor for early mortality (odds ratio = 9.5; 95% confidence interval = 1.4-63.7; P = 0.020). Twelve patients required a total of 29 procedures in 17 reoperations. Five patients required reoperation for autograft failure at a median of 14 years (range, 5-15 years) postoperatively. Estimated freedom from all causes of reoperation at 5, 10 and 15 years was 82, 55 and 30%, respectively. All patients had complete and durable relief of LVOTO. At latest follow-up, 5 patients had a sinus of Valsalva Z-score of 5 or greater. One patient had Grade II autograft insufficiency. CONCLUSIONS The Ross-Konno procedure is a durable solution for multilevel LVOTO in a highly complex patient population with high incidence of previous procedures. High early mortality rates in patients with impaired left ventricular function emphasize the importance of patient selection. Freedom from reoperation shows a continuous attrition rate. Reoperation for autograft failure may occur late after the Ross-Konno procedure.