The Dilemma of Pulmonary Valve Replacement In Patients With Repaired Tetralogy of Fallot

: Patients with repaired tetralogy of Fallot often have pulmonary valvar regurgitation with variable degrees of right ventricular dilatation, which may lead to dysfunction of both ventricles. Therefore, some patients may need pulmonary valve replacement. This calls for adequate patient selection, and there are ventricular volumetric guidelines to aid this. However, pulmonary valve replacement has caused a dilemma because: 1- It often does not reverse right ventricular dilatation back to normal nor prevent arrhythmias. 2- It is argued that right ventricular dilatation occurs early after repair of tetralogy of Fallot but remains stable thereafter. 3- The patient’ prognosis is said to be affected mainly by the function of the left ventricle rather than that of the right ventricle. 4- Prosthetic valves on the right side of the heart are more prone to infection as compared to the left side since bacteria can reach them easily. All these concerns are examined in this Opinion Article. Overall, this dilemma is justified but usually not sufficiently elaborated and often gives the incorrect message that this procedure is of no benefit. The reality is, however, that pulmonary valvar regurgitation is a harmful condition and deserves to be remedied on hemodynamic grounds. The dilemma arises because hemodynamic improvement after valve implantation may be partial, and many think that this is not enough to justify an intervention, especially with the added risk of endocarditis. However, if valve replacement is to be offered, this should be done in a timely fashion; waiting too long is associated with a worse outcome.