The impact of tricuspid regurgitation on timing pulmonary valve replacement in ACHD patients after tetralogy of Fallot repair

The emerging role of tricuspid regurgitation in the long-term outcome of the general population, poses the need for a review of its impact on patients with TOF and the timing for surgical PVR. This is a retrospective, single Centre study. Clinical, imaging and surgical data of adults with repaired TOF with a transannular patch repair were collected from our database. 149 patients (61% male, mean age of 26.0 years) were selected. At a follow-up time of 25.5 years (95% CI 24.5,26.4) 92 patients required isolated PVR at a mean time from TOF repair of 16.6 years (95% CI 15.5,17.7) and at a mean age of 17.9 years (95% CI 16.8,19.0). In the whole cohort, significant TR was associated with a two-fold increase likelihood of requiring PVR (log-rank p = 0-.0023, HR 2.02; 1.09-4-47). Moderate to severe TR was more frequent in those who underwent VSD closure through a right atriotomy (17 versus 0, p = .0002) and affected time to PVR (22.10 yrs versus 18.07 yrs). Despite significant RV volume overload, only 16% of the entire cohort had TR more than moderate, and the degree of TR and tricuspid valve annulus diameter correlated better with atrial rather than ventricular volumes and areas (r=0.346; p =0.0068). The TR severity, correlated with surgical type of VSD closure, confers two-fold increase in the likelihood of requiring PVR during follow-up. The close correlation of TV with atrial rather than ventricular volumes is in keeping with the non-functional nature of TR. Figure Graphical Abstract (Implications): The preoperative degree of TR may significantly impact whether patients require PVR at a younger age. The close correlation of TV with atrial instead of ventricular volumes explains the degenerative nature of the tricuspid regurgitation. • The severity of preoperative TR in adults with repaired tetralogy of Fallot, linked to type of VSD closure, may lead to earlier PVR and shorter valve durability. • TV correlates with atrial volumes, suggesting a primary rather than functional nature of TR. • Concomitant tricuspid valve repair during PVR may improve outcomes, potentially reshaping future clinical guidelines for managing TR and PVR in these patients.