Lee C, et al. - Researchers investigated long-term outcomes of pulmonary valve replacement (PVR) in patients with repaired tetralogy of Fallot (TOF). Further, they sought for the factors correlated with adverse clinical events (ACEs; defined as all-cause death, heart transplantation or new-onset sustained arrhythmia). They retrospectively analyzed a total of 190 patients who underwent PVR between 1998 and 2015 after repair of TOF. At PV, the median age was 19 years. Patients with repaired TOF exhibited satisfactory long-term outcomes of PVR. At 15 years, the transplantation-free survival and freedom from ACE were 95% and 90%, respectively. ACE was observed to be associated with the following factors: older age at PVR, older age at TOF repair, New York Heart Association functional class III or IV, presence of tachyarrhythmias, longer cardiopulmonary bypass time and concomitant arrhythmia surgery. In a subgroup analysis of 143 patients with preoperative MRI data, ACE was observed in correlation to larger RV end-systolic volume index, larger left ventricular end-systolic volume index and lower left ventricular ejection fraction. The long-term survival of this patient population may further improve with proactive PVR before the onset of advanced symptoms, tachyarrhythmias, and ventricular dysfunction.