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Objectives Aortic root replacement using a composite graft is the treatment of choice for a large variety of aortic root conditions with a diseased aortic valve. The objective of the current study was to evaluate the long-term results of this procedure. Methods Between 1978 and 2010, 1045 patients aged 58.7 ± 13.6 years underwent aortic root composite graft replacement using the following techniques: 95 Bentall operation; 926 the “button technique;” 24 the Cabrol technique. A mechanical composite valve graft was implanted in 69.6% of the patients. Six-hundred and thirty-five patients (62.3%) had annuloaortic ectasia and 162 (15.5%) had aortic dissection. Results Early mortality was 5.3% (55/1045). Independent risk factors for early mortality at logistic regression analysis were age ≥70 years ( P = .051; odds ratio [OR], 2.97), New York Heart Association III-IV ( P = .052; OR, 1.88), reoperation ( P = .021; OR, 2.36), urgency/emergency ( P = .003; OR, 3.09), mitral valve replacement ( P = .001; OR, 6.01), or coronary artery bypass grafting (CABG) ( P < .001; OR, 4.39); while bicuspid aortic valve (BAV) ( P = .013; OR, 0.21), and time of operation 2001-2011 ( P = .025; OR, 0.60) were protective predictors for early mortality. Overall survival at 5, 10, and 20 years was 84.1% ± 1.3%, 65.5% ± 2.6%, and 40.7% ± 4.6%, respectively. Multivariate analysis revealed chronic renal insufficiency ( P = .001; hazard ratio [HR], 3.48), chronic obstructive pulmonary disease ( P = .027; HR, 1.94), aortic dissection ( P = .001; HR, 2.63), Cabrol technique ( P = .009; HR, 15.34), and CABG ( P = .016; HR, 2.02) to be significant predictors of late death, and BAV ( P = .010; HR, 0.43) to be a significant protective predictor. Freedom from thromboembolism, bleeding complications, and endocarditis was 93.7% ± 2.6%, 90.3% ± 3.1%, and 98.4% ± 1% at 20 years, respectively. Freedom from aortic reoperation was 91.8% ± 2.1% at 20 years and was significantly lower in patients with aortic dissection. Conclusions Within the limitations of this retrospective study, we can conclude that aortic root replacement for aortic root aneurysms can be performed with low morbidity and mortality and with satisfactory long-term results. Few late serious complications were related to the need for long-term anticoagulation or a prosthetic valve. Reoperation on the proximal or in the distal aorta was most commonly performed in patients with aortic dissection. [ABSTRACT FROM AUTHOR]