: Although survival after congenital cardiac malformations (CCM) has improved, little is known about Romanian children's own perceptions of health-related quality of life (HRQoL) or their emotional burden. We compared HRQoL, depressive symptoms, and anxiety across lesion severity strata and explored clinical predictors of impaired HRQoL. : In this cross-sectional study (1 May 2023-30 April 2025), 72 children (mean age 7.9 ± 3.0 years, 52.8% male) attending a tertiary cardiology clinic completed the Romanian-validated Pediatric Quality of Life Inventory (PedsQL), Children's Depression Inventory (CDI) and the Screen for Child Anxiety-Related Emotional Disorders questionnaire (SCARED-C, child version). Lesions were classified as mild ( = 22), moderate ( = 34), or severe ( = 16). Left-ventricular ejection fraction (LVEF) and unplanned cardiac hospitalisations over the preceding 12 months were extracted from electronic records. : Mean PedsQL total scores declined stepwise by severity (mild 80.9 ± 7.3; moderate 71.2 ± 8.4; severe 63.1 ± 5.4; < 0.001). CDI and SCARED-C scores rose correspondingly (CDI: 9.5 ± 3.0, 13.6 ± 4.0, 18.0 ± 2.7; anxiety: 15.2 ± 3.3, 17.2 ± 3.8, 24.0 ± 3.4; both < 0.001). PedsQL correlated positively with LVEF (r = 0.51, < 0.001) and negatively with hospitalisations (r = -0.39, = 0.001), depression (r = -0.44, < 0.001), and anxiety (r = -0.47, < 0.001). In multivariable analysis, anatomical severity remained the sole independent predictor of lower HRQoL (β = -8.4 points per severity tier, < 0.001; model R = 0.45). Children with ≥ 1 hospitalisation ( = 42) reported poorer HRQoL (69.6 ± 8.0 vs. 76.1 ± 11.1; = 0.005) and higher depressive scores ( < 0.001). : HRQoL and internalising symptoms in Romanian children with CCM worsen with increasing anatomical complexity and recent hospital utilisation. The severity tier outweighed functional markers as the main determinant of HRQoL, suggesting that psychosocial screening and support should be scaled to lesion complexity. Integrating the routine use of the Romanian-validated PedsQL, CDI, and SCARED-C questionnaire into cardiology follow-up may help identify vulnerable patients early and guide targeted interventions.