Summary of different consensus criteria for pulmonary valve replacement (PVR) in patients with repaired tetralogy of Fallot (TOF)

INDICATOR cohort "proactive" criteria^[1]	INDICATOR cohort "conservative" criteria^[1]	2018 American Heart Association/ American College of Cardiology adult CHD guidelines^[2]	2020 European Society of Cardiology adult CHD guidelines^[3]	2022 Canadian Cardiovascular Society adult CHD guidelines^[4]
PR regurgitant fraction >25%, plus ≥2 of the following: RVEDVi >160 mL/m² RVESVi >80 mL/m² RVEF <47% LVEF <55% QRS duration >160 ms	PR regurgitant fraction >25%, plus ≥2 of the following: RVEDVi >180 mL/m² RVESVi >95 mL/m² RVEF <40% LVEF <45% QRS duration >180 ms	Moderate or greater PR, plus: Cardiovascular symptoms not otherwise explained, or ≥2 of the following: RVEDVi ≥160 mL/m² RVEDV ≥2× LVEDV RVESVi ≥80 mL/m² Mild or moderate RV or LV systolic dysfunction Objectively reduced exercise capacity Significant RVOTO (RVp ≥2/3 systemic pressure) Ventricular tachyarrhythmia	Severe PR, plus ≥1 of the following: Cardiovascular symptoms not otherwise explained RVEDVi ≥160 mL/m² RVESVi ≥80 mL/m² Moderate or greater TR Progressive RV systolic dysfunction Objectively reduced exercise capacity Significant RVOTO (RVp >80 mmHg)	Severe PR (regurgitant fraction >25% on CMR or qualitatively severe by echocardiography), plus ≥1 of the following: Cardiovascular symptoms not otherwise explained RVEDVi ≥160 mL/m² RVESVi ≥80 mL/m² RV systolic dysfunction Objectively reduced exercise capacity Significant RVOTO (RVp ≥2/3 systemic pressure) Sustained ventricular tachyarrhythmia

This table summarizes criteria used to identify candidates for PVR among patients with repaired TOF as endorsed by various professional societies and expert panels. Most experts agree that the decision to perform PVR should be based on the severity of PR, presence of associated symptoms, and quantitative measurements of RV volume and function as assessed by CMR. However, the specific thresholds vary somewhat between different resources, as highlighted above. Ideally, PVR should be performed before RV dysfunction develops. For additional details, refer to UpToDate topics on long-term follow-up and management after TOF repair.

CHD: congenital heart disease; CMR: cardiovascular magnetic resonance; LV: left ventricle; LVEDV: left ventricular end-diastolic volume; LVEF: left ventricular ejection fraction; PR: pulmonary regurgitation; PVR: pulmonary valve replacement; RV: right ventricle; RVEDV: right ventricular end-diastolic volume; RVEDVi: right ventricular end-diastolic volume index; RVEF: right ventricular ejection fraction; RVp: right ventricular systolic pressure; RVESVi: right ventricular end-systolic volume index; RVOTO: right ventricular outflow tract obstruction; TOF: tetralogy of Fallot; TR: tricuspid regurgitation.

References:

Bokma JP, Geva T, Sleeper LA, et al. Improved outcomes after pulmonary valve replacement in repaired tetralogy of Fallot. J Am Coll Cardiol 2023; 81:2075.
Stout KK, Daniels CJ, Aboulhosn JA, et al. 2018 AHA/ACC guideline for the management of adults with congenital heart disease: A report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines. Circulation 2019; 139:e698.
Baumgartner H, De Backer J, Babu-Narayan SV, et al. 2020 ESC guidelines for the management of adult congenital heart disease. Eur Heart J 2021; 42:563.
Marelli A, Beauchesne L, Colman J, et al. Canadian Cardiovascular Society 2022 guidelines for cardiovascular interventions in adults with congenital heart disease. Can J Cardiol 2022; 38:862.

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Summary of different consensus criteria for pulmonary valve replacement (PVR) in patients with repaired tetralogy of Fallot (TOF)