The optimal timing of pulmonary valve replacement (PVR) in adults with repaired Tetralogy of Fallot (TOF) and severe pulmonary regurgitation remains controversial, particularly in older patients. Current recommendations rely largely on right ventricular volumes assessed by cardiac magnetic resonance imaging (MRI), although their prognostic value remains debated.

We conducted a retrospective single-center study including patients aged ≥ 30 years with repaired TOF who underwent surgical PVR between 2009 and 2018. The primary outcome was a composite endpoint including supraventricular arrhythmia, cardiovascular rehospitalization, or all-cause death during follow-up. Clinical, imaging, and hemodynamic variables were analyzed using univariate and multivariate logistic regression.

Forty-eight patients (mean age at PVR 41 ± 9.8 years) were included, with a mean follow-up of 52 months. The primary outcome occurred in 23 patients (48%). Preoperative signs of advanced disease, including right heart failure, left ventricular dysfunction, and a history of syncope or ventricular tachycardia, were associated with adverse outcomes. In multivariate analysis, elevated right ventricular end-diastolic pressure (RVEDP) was the only independent predictor of postoperative morbidity and mortality (OR 1.49, 95% CI 1.01–3.40; P = 0.04). Preoperative right ventricular volumes assessed by MRI were not associated with the primary outcome in multivariate analysis.

In adults aged ≥ 30 years with repaired TOF undergoing PVR, elevated RVEDP is a key predictor of postoperative morbidity and mortality, whereas right ventricular volumes on MRI are not. Invasive hemodynamic assessment may help refine the timing of PVR in this “senior” population.