Outcomes after tetralogy of Fallot repair with preservation of intact pulmonary valve structure

The optimal post-repair pulmonary valve annulus (PVA) diameter in tetralogy of Fallot (TOF) may be far smaller than anticipated. Therefore, selected patients can undergo repair without manipulating the PV structure. Of the 347 patients who underwent TOF repair with PVA preservation (AP) from January 2016 to December 2023, 100 had AP while leaving the PV structure untouched. Median age, weight, and PVA (Z) at repair were 125 days (interquartile range [IQR], 96.5–167.5), 6.3 kg (IQR, 5.1–7.1), and −0.8 (IQR, −1.8 to 0.3), respectively. One non-cardiac late death occurred 9 months after repair. During a median 46.2 months follow-up, 14 patients (14%) required reinterventions for significant right ventricular outflow tract obstruction (RVOTO): balloon pulmonary valvuloplasty (BPV) in 6, surgical RVOTO relief in 4, and BPV followed by surgery in 4 (including 1 who received a right ventricle to pulmonary artery conduit to bypass a left anterior descending coronary artery crossing the RVOT). Except for the conduit recipient, only 2 patients showed significant RVOTO (n = 1) and significant pulmonary regurgitation (PR) (n = 1) at the last follow-up. On Cox regression, neonatal repair (hazard ratio [HR], 5.12, P  = 0.02) and a higher P _RV/LV (post-repair pressure ratio of the right ventricle to the left ventricle) (HR 1.61 per 0.1 increase, P  = 0.04) were risk factors for decreased time to reintervention. The post-repair P _RV/LV cutoff predicting reintervention was 0.52. Preserving an intact PV during TOF repair is feasible in a subset. Post-repair RVOTO, when it occurs, can be relieved by a timely reintervention without inducing significant PR.