The problems related with primary repair for tetralogy of Fallot, especially about transannular patch repair

Since the initial surgical correction of tetralogy of Fallot (TOF) in 1954, advances in management have helped reduce early surgical mortality to less than 2% (1). During six decades, the surgical approach has shifted from repair via a right ventriculotomy to a transatrial-transpulmonary approach, as many congenital cardiac surgeons consider relieving right ventricular outflow tract (RVOT) obstruction with preserving pulmonary valve competence as important factors to guarantee long term outcomes (2-4). The STS database reported the recent trend in TOF operations, which revealed over 60% surgeries still using transannular patch enlargement (TAPE) (5). These data suggested us to consider the reason of using TAPE. Recent trends revealed many centers used the pulmonary valve annulus (PVA) z-score to determine whether to apply the TAPE procedure, but the cutoff value for this measure varies among studies (−1.3 to −4) (6,7).