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Abstract Tetralogy of Fallot (TOF) represents 7–10% of congenital heart disease (CHD) occurring in 0.5/1000 live births and is considered the second most common form of complex CHD. Although frequently fatal without surgical intervention, advances in one or two-stage surgical repair in the recent era facilitates survival of the affected patients into adulthood with good quality of life, however with long-term complications and residual lesions. After many years of experience with surgical repair of tetralogy of Fallot (TOF), we concluded that longstanding pulmonary insufficiency is deleterious for right ventricular function and clinical outcome. This subsequently enhanced the search for surgical techniques aiming to relief the right ventricular outflow tract (RVOT) obstruction, with minimizing the resultant pulmonary regurgitation (PR) as possible. |