OBJECTIVES: To evaluate the midterm outcomes of the Ross and Ozaki procedures as alternatives to mechanical valve replacement in children with aortic valve disease. METHODS: All patients undergoing the Ross or Ozaki procedure between January 2017 and December 2023 were included. Primary outcomes were moderate or greater aortic valve stenosis (AS) or aortic regurgitation (AR) after surgery. Secondary outcomes included reoperations. RESULTS: The cohort comprised 54 patients, with 35 patients (65%) undergoing the Ross procedure and 19 (35%) the Ozaki procedure. The mean age at surgery was 8.5 years (SD: 4.0). Patients undergoing the Ozaki procedure had more cases of predominant AR and large aortic valve annuli compared to the Ross group. The median follow-up time was 3.8 years (IQR, 2.0-5.3 years). Freedom from moderate or greater AS/AR was 92% at 2 years and 88% at 4 years in the Ross group, versus 59% at 2 years and 30% at 4 years in the Ozaki group (P <
0.001). Freedom from neoaortic valve reoperation was 100% at 2 years and 94% at 4 years in the Ross group, compared to 92% at 2 years and 71% at 4 years in the Ozaki group (P = 0.002). Overall freedom from any reoperation was similar between groups (P = 0.16). CONCLUSIONS: The Ross procedure appears to provide a more durable neoaortic valve, particularly for patients with predominant AS or mixed lesions. The Ozaki procedure, primarily performed in patients with AR in our cohort, showed suboptimal midterm outcomes. Further studies with larger cohorts are needed to validate these findings.