BACKGROUND: With renewed enthusiasm for the Ross procedure in adults in recent years, long-term data using contemporary techniques are needed. OBJECTIVES: The purpose of this study was to evaluate long-term clinical and echocardiographic outcomes of the Ross procedure in a contemporary adult cohort. METHODS: From 2011 to 2019, 455 consecutive adults (mean age 47 ± 12 years; 73% male) underwent a Ross procedure at a single high-volume tertiary center. This includes our inaugural experience with the procedure. All patients were prospectively followed with systematic clinical and echocardiographic follow-up. Outcomes included operative safety, long-term survival, reinterventions, valve hemodynamics, and autograft root dimensions. Median follow-up was 9.0 years (Q1-Q3: 7.3-11.1 years), with 98% completeness of clinical and echocardiographic follow-up (4,191 patient-years and 2,921 echocardiograms). RESULTS: Operative mortality was 0.4% (n = 2). No patient-prosthesis mismatch occurred, and permanent pacemaker implantation was required in 0.8% (n = 3). At 12 years, actuarial survival was comparable to the age- and sex-matched general population. The cumulative incidence of autograft reintervention at 12 years was 1.1% ± 0.5%, with no difference between patients with preoperative aortic regurgitation and aortic stenosis (1.2% ± 1.2% vs 1.1% ± 0.6%; P = 0.39, respectively). The cumulative incidence of pulmonary homograft reintervention at 12 years was 1.9% ± 0.9%, and any cardiac reintervention was 3.5% ± 1.0% at 12 years. Mean aortic valve gradient at 12 years was 4.0 ± 0.2 mm Hg. CONCLUSIONS: In a large contemporary adult cohort with comprehensive follow-up, the Ross procedure was associated with excellent long-term survival, durable valve performance, and low reintervention rates, including in patients with preoperative aortic regurgitation and those >50 years of age. These findings provide an important contemporary benchmark and support broader consideration of the Ross procedure in appropriately selected adults in experienced centers.