Systematic Review and Meta-regression of Longitudinal Outcomes of Pulmonary Valve Replacement in Tetralogy of Fallot

Background Despite excellent survival following Tetralogy of Fallot (TOF) repair, pulmonary regurgitation (PR) is common. Pulmonary valve replacement (PVR) is frequently performed, but its long-term efficacy remains uncertain. We conducted a meta-regression to assess the impact of PVR on key cardiac outcomes over time. Methods We included studies reporting PR, right ventricular (RV) and left ventricular volumes (LV), QRS duration, RV ejection fraction (RVEF), peakVO 2 , or NYHA class before and after PVR in patients with TOF. A multilevel random-effects meta-regression was performed using time since PVR as a covariate. Cubic splines were used to explore temporal trends, and meta-analysis to quantify the impact of PVR over time. Results Sixty-nine studies were included. Compared with pre-PVR values, PVR yielded substantial absolute reductions in PR fraction, RV end-systolic and end-diastolic volume. LV end-diastolic volume increased slightly. NYHA class also improved. Median follow-up was 14.4 months (IQR: 10.3-31.1) with only one study extending beyond 10 years. Estimated annual changes after PVR were minimal for all parameters and negligible for key parameters such as PR fraction (0.36%, 95%CI: –0.05% to 0.77%), RV end-systolic volume (–0.58 mL/m 2 , 95%CI: –1.62 mL/m 2 to 0.45 mL/m 2 ), RV end-diastolic volume (–0.49 mL/m 2 , 95%CI: –0.72 mL/m 2 to 1.72 mL/m 2 ). Conclusions The long-term impact of PVR remains uncertain. While short-term improvements are clear, insufficient long-term data preclude firm conclusions on sustained benefits.