Pulmonary valve (PV) preservation during Tetralogy of Fallot (TOF) repair remains challenging, particularly in patients with small pulmonary annuli. We previously described a standardized and reproducible pulmonary valve–sparing technique based on conservative management of the native valve to preserve its growth potential. We report the mid-term outcomes of the same cohort with extended follow-up.

Between July 2015 and December 2019, 23 consecutive children with regular TOF underwent repair using this technique in a single centre. Median age at surgery was 7 months (range: 4.5–150.4; IQR: 4.3) and median weight was 6.7 kg (range: 4.8–24.0; IQR: 2.5). Nineteen patients (82%) had a bicuspid pulmonary valve. Median pulmonary annulus diameter was 7.0 mm (range: 5.0–14.0; IQR: 2.5), with a median z-score of −2.5 (range: −4.9 to −0.02; IQR: −1.6). The technique combines T-shaped infundibulotomy to release the anterior annulus, extensive commissurotomy following ventricular septal defect closure, and right ventricular outflow tract (RVOT) remodeling using a shield-shaped bovine patch attached to the annulus, creating systolic traction.

At discharge, all patients had pulmonary regurgitation (PR) less than moderate. After a median follow-up of 60.9 months (range: 8.4–105.1; IQR: 32.6), the median maximal gradient was 21.0 mmHg (range: 9.0–46.2; IQR: 11.0), with only one patient having a gradient above 31.0 mmHg (46.2 mmHg), and all others below 31.0 mmHg. At the latest follow-up, severe PR was observed in 4 patients (17%) and moderate PR in 2 patients (8%), while the remaining patients had PR less than moderate. No patient required surgical or transcatheter reintervention on the RVOT.

This pulmonary valve–sparing approach demonstrates stable mid-term hemodynamic performance despite small annular dimensions at repair. Although progression of PR was observed in a subset of patients, gradients remained acceptable and no RVOT reintervention was necessary.