Late cardiovascular complications after operative repair of coarctation of the aorta include systemic hypertension, premature coronary artery disease, aortic valve abnormalities, aortic aneurysm, and recoarctation. We report the outcome in 274 subjects greater-than-or-equal50 years after coarctation repair. Operative repair of simple coarctation was performed on 274 patients at the University of Minnesota Hospital between 1948 and 1976. Twenty patients (7%) died in the immediate postoperative period. Of the 254 survivors, 2 were lost to follow-up, 45 (18%) died at a mean age of 34 years, and 207 (81%) were alive greater-than-or-equal50 years after the original operation. Coronary artery disease and perioperative deaths at the time of a second cardiac operation accounted for 17 of the 45 late deaths. Predictors of survival were age at operation and blood pressure at the first postoperative visit. Of the 207 long-term survivors, 92 (48%) participated in a clinical cardiovascular evaluation. Thirty-two of the 92 subjects had systemic hypertension that was predicted by age at operation, blood pressure at the first postoperative visit, and paradoxic hypertension at operative repair. New cardiovascular abnormalities detected at follow-up evaluation included evidence of a previous myocardial infarction, cardiomyopathy, atrial fibrillation, moderate to severe left ventricular outflow tract obstruction, moderate aortic valve regurgitation, recoarctation, and ascending aortic dilation. Thus, long-term survival is significantly affected by age at operation, with the lowest mortality rates observed in patients who underwent surgery between 1 and 5 years of age. More than 1/3 of the survivors developed significant late cardiovascular abnormalities.