The Society of Thoracic Surgeons / World Society for Pediatric and Congenital Heart Surgery / European Congenital Heart Surgeons Association 2026 Expert Consensus Document on Timing, Indications, and Options for Pulmonary Valve Replacement in Children with Repaired Tetralogy of Fallot.

Abstract

Contemporary surgical and medical management has enabled excellent long-term survival and quality of life for children following repair of tetralogy of Fallot. However, most patients are left with residual pulmonary regurgitation that requires long-term surveillance and eventual pulmonary valve replacement to prevent right ventricular failure. Guidelines have been developed regarding the indications for and timing of pulmonary valve replacement in adults, but such do not exist for children. This expert consensus document aimed to address those gaps by supporting clinical decision-making regarding the surgical and transcatheter management of chronic pulmonary regurgitation in children with repaired tetralogy of Fallot. The Society of Thoracic Surgeons Workforce on Evidence Based Surgery assembled a multidisciplinary expert panel composed of congenital surgeons and cardiologists. A focused literature review was performed, and expert consensus statements were developed using a Modified Delphi process and clustered under two key topics: (1) pediatric-specific considerations and (2) surgical versus transcatheter techniques. Consensus was reached for 13 recommendations. The recommendation statements reflect contemporary expert opinion on the timing and decision-making for pulmonary valve replacement in children. While decision-making regarding the management of chronic pulmonary regurgitation after repair of tetralogy of Fallot in children is complex, this document provides guidance for congenital heart teams to optimize management based on a synthesis of contemporary evidence.