Preoperative Pulmonary Valve Annulus Diameter Z Score as a Predictor of Pulmonary Regurgitation after Tetralogy of Fallot Repair: A Retrospective Cohort Study

Preoperative Pulmonary Valve Annulus Diameter Z Score as a Predictor of Pulmonary Regurgitation after Tetralogy of Fallot Repair: A Retrospective Cohort Study | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Preoperative Pulmonary Valve Annulus Diameter Z Score as a Predictor of Pulmonary Regurgitation after Tetralogy of Fallot Repair: A Retrospective Cohort Study Pribadi Wiranda Busro, Ahmad Adityawarman, Suprayitno Wardoyo, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8793939/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 18 You are reading this latest preprint version Abstract Background Tetralogy of Fallot (ToF) is the most common cause of cyanotic congenital heart disease and pulmonary regurgitation (PR) remains the most frequent complication after ToF repair, affecting a patient’s long-term prognosis. The preoperative z score of the pulmonary valve annulus (PVA) has been shown to be associated with an increased risk of significant PR after ToF repair; however, the optimal cut-off value varies among studies and has not been investigated in the Indonesian population. This study aimed to determine the predictive value of the preoperative PVA z score diameter for the occurrence of PR after ToF repair. Methods A retrospective cohort study was conducted using secondary data from pediatric patients who underwent ToF repair at the National Cardiac Center Harapan Kita between January 2023 and December 2024. The preoperative PVA diameter was measured via cardiac multislice computed tomography (MSCT). The outcome, early PR, was assessed via echocardiography within 45 days post-operatively. Multivariable logistic regression was performed and receiver operating characteristic (ROC) curve analyses were used to identify optimal cut-off values. Results A total of 101 subjects were analysed. There was a significant association between the maximal and minimal diameters of the PVA z scores (p = 0,001 and p < 0,001, respectively) with significant PR in the univariate analysis. Multivariate analysis revealed that only the minimal diameter of the PVA z-score remained significant (p < 0,001). ROC analysis revealed that the minimal diameter of the PVA z score (area under the curve [AUC] 0,701; cut-off − 2,5) demonstrated moderate discriminatory ability in predicting early PR, with high specificity (90,6%) but limited sensitivity (42%). Conclusion The z score of the PVA minimal diameter, measured by preoperative MSCT, was consistently associated with early significant PR after ToF repair and may assist early risk stratification, although its predictive value should be interpreted alongside other clinical and intraoperative factors. Tetralogy of Fallot pulmonary valve annulus pulmonary annulus z score pulmonary regurgitation cardiac surgery Figures Figure 1 Figure 2 1. Background Tetralogy of Fallot (ToF) is the most common form of cyanotic congenital heart disease, accounting for approximately 3–5% of all congenital heart diseases with an incidence of 0,28 − 0,34 per 1000 live births. 1 The survival rate for patients who undergo surgical repair of ToF is as high as 95% at the age of 40 years. 2 Pulmonary regurgitation (PR) is the most frequent complication after ToF repair surgery in the middle- and long-term. Chronic PR may lead to right ventricular overload, ventricular dysfunction, arrhythmia, and other cardiovascular complications including sudden death such that it influences the overall prognosis. 3 , 4 Moderate-to-severe PR in the early postoperative period has been shown to be a risk factor for the development of midterm PR; therefore, early detection is important. 5 In some ToF patients, right ventricular outflow tract stenosis can be released optimally with transannular patch (TAP) insertion, but this technique is the main risk factor for consequent PR. 6 The size of the pulmonary valve annulus (PVA) is the main predictor of the TAP requirement, and a low PVA z score was associated with the incidence of postoperative PR in some studies. 5 , 7 The PVA z-score, which is a calculation used to normalize the PVA size to the patient’s body surface area, is a more informative calculation than the absolute measurement alone. Most previous studies relied on echocardiographic measurements assuming a circular annulus, potentially underestimating annular asymmetry. 8 Data on the use of multislice computed tomography (MSCT)-derived PVA diameter as a predictor of early postoperative PR limited. This study aimed to assess the role of the preoperative PVA diameter z-score, measured via cardiac MSCT, in the prediction of PR after ToF repair at our center, which is a national cardiac surgery referral center and has unique population characteristics compared with those reported abroad. Determining the z score cut-off for predicting postoperative PR will provide important contributions to both surgical strategy planning and follow-up after surgery including long-term patient monitoring. 2. Patients and methods Study design and definitions This retrospective cohort study enrolled patients underwent ToF repair surgery from January 2023-December 2024 at the National Cardiac Center Harapan Kita. Ethical approval was obtained retrospectively from the Committee on Institutional Review Board/Health Research Ethics of National Cardiac Center Harapan Kita Hospital on October 6, 2025 under approval number DP.04.03/KEP164/EC102/2025. A total of 101 patients were included in this study. The subjects were patients aged < 18 years without complex congenital disorders such as ToF patients with atrioventricular septal defects, anomalous pulmonary vein drainage, absence of the pulmonary valve, pulmonary atresia, and coronary artery anomalies. We also excluded patients who had undergone systemic to pulmonary artery shunt surgery or palliative procedures such as modified BTT shunt, central shunt, PDA stenting, and right ventricular outflow tract (RVOT) stenting before ToF repair surgery. Research data, including preoperative MSCT and postoperative echocardiography data, were obtained from patient medical records. The PVA diameter was measured retrospectively from preoperative cardiac MSCT recordings. To ensure accurate PVA measurement, multiplanar reformation (MPR) was performed at the annular level to obtain the most ideal circular image, and then the minimum and maximum diameters were measured. 8 The obtained minimum and maximum diameters were then substituted into the z score formula. 8 Body surface area (BSA), which is incorporated into the z-score calculation, was determined using the Haycock formula. The PR assessment was based on transthoracic echocardiography performed during the outpatient visit within 45 days after the operation via a parasternal short-axis view. Echocardiography recordings were considered adequate if they provided a sufficient field of view and good image quality. The severity of PR was divided into two categories: significant and not significant. Not significant PR is a PR with a mild or lower degree, where the criteria for mild PR are the presence of diastolic reversal flow in the main PA, a small and narrow jet (< 10 mm), and a PR/RVOT jet width ratio of < 0.2. A significant PR is a moderate PR or greater. The criteria for moderate PR are diastolic reversal flow at the pulmonary artery (PA) bifurcation, an intermediate jet size, and a PR/RVOT jet width ratio of 0.2–0.5. The criteria for severe PR are diastolic reversal flow in the PA branches, a wide jet size on color Doppler with varying penetration depths, a PR/RVOT jet width ratio of > 0.5, dense jet density and contour with early diastolic flow termination, and a pressure half time (PHT) of < 100 ms. 9–11 Statistical analysis Data analysis was performed via SPSS for Windows (version 27, 2020). Patients were divided into two groups on the basis of postoperative PR: those with significant PR and those with no significant PR. Quantitative variables are displayed as the mean ± standard deviation (SD) or median (interquartile range). Categorical data are displayed as proportions (%). Bivariate analysis of the relationships between quantitative variables and categorical variables was performed via the unpaired t test or Mann-Whitney test. The chi-square or Fisher’s exact test was used to analyse the relationships between categorical variables of groups. Variables with a significant p value < 0.25 in the bivariate analysis were included in the multivariate analysis via logistic regression. Results with a p-value < 0.05 were considered statistically significant. The cut-off value of the PVA z score for predicting PR was obtained via a receiver operating characteristic (ROC) curve. 3. Results A total of 101 patients who met the criteria were included in the study. The median age at surgery was 38 months, with a range of 7-162 months. The median weight was 11.16 kg, with a range of 5.5–39 kg. Other patient characteristics are shown in Table 1 . The average z scores of the preoperative PVA maximum and minimum diameters were − 2.22 ± 1.23 and − 1.88 ± 1.24, respectively. TAP insertion was performed in the majority of patients (64.4%). An echocardiography study after ToF repair surgery revealed that significant PR occurred in 68.3% of patients. Table 1 Subject characteristics Total n = 101 Age at surgery (months) 38 (7-162) Gender Male 63 (62.4%) Female 38 (37.6%) Weight (kg) 11.16 (5.50–39.00) Height (cm) 88 (61.00-162.00) BSA (m 2 ) 0.54 (0.33–1.31) McGoon ratio 2.10 (1.32–3.30) PVA z score Maximal diameter -2.22 ± 1.23 Minimal diameter -1.88 ± 1.24 TAP No 36 (35.6%) Yes 65 (64.4%) Significant pulmonary regurgitation No 32 (31.7%) Yes 69 (68.3%) PVA diameters were independently measured by two observers via MSCT images and interobserver reliability was assessed via the intraclass correlation coefficient (ICC). Excellent agreement was observed for the maximum PVA diameter (ICC = 0.939; 95% CI: 0.881–0.969; p < 0.001); Cronbach’s alpha = 0.971) and good agreement was observed for the minimum PVA diameter (ICC = 0.898; 95% CI: 0.808–0.947; p < 0.001; Cronbach’s alpha = 0.945). Interobserver agreement for postoperative PR assessment via echocardiography was good (Kappa = 0.727; p = 0.001), whereas intraobserver agreement was perfect (Kappa = 1.0; p < 0.001). According to univariate analysis, the PVA z score was significantly associated with the incidence of significant PR (Table 2 ), with p < 0.001 for the minimum diameter and p = 0.001 for the maximum diameter. Patients with significant PR had lower mean z scores of the maximum PVA diameter (-2.5 ± 1.17) and lower mean z scores of the minimum PVA diameter (-2.17 ± 1.18). Table 2 Risk factor analysis for pulmonary regurgitation after ToF repair Variables Not significant PR (n = 32) Significant PR (n = 69) P Age at surgery (months) 56.5 (7-139) 34 (8-162) 0.140 Gender Male 17 (27%) 46 (73%) 0.191 Female 15 (39.5%) 23 (60.5%) Weight (kg) 12 (6.6–28) 10.8 (5.5–39) 0.193 Height (cm) 99 (67–129) 85 (61–162) 0.122 BSA (m 2 ) 0.57 (0.35–0.99) 0.51 (0.33–1.31) 0.167 McGoon ratio 2.18 (1.57–3.3) 2.1 (1.32–3.2) 0.876 PVA z-score Maximal diameter -1.65 ± 1.19 − 2.5 ± 1.17 0.001 Minimal diameter -1.25 ± 1.15 -2.17 ± 1.18 < 0.001 ROC analysis was performed for the PVA z score parameters to predict the occurrence of significant PRs. Both the maximum and minimum PVA diameter z scores demonstrated moderate discriminative ability for predicting significant pulmonary regurgitation, with area under the curve (AUC) values of 0.695 and 0.701, respectively. A cut-off value of -2.1 for the z-score of the PVA maximum diameter (95% CI: 0.59–0.81) yielded a sensitivity of 66.7% and a specificity of 68.7% (Fig. 1 ). A cut-off value of -2,5 for the z score of the PVA minimum diameter (95% CI: 0.60–0.81) yielded a sensitivity of 42% and a specificity of 90.6% (Fig. 2 ), demonstrating high specificity but limited sensitivity, indicating its utility in ruling in, rather than ruling out, early PR. Multivariate analysis was performed via binary logistic regression with the backwards LR method. Risk factors with P values < 0.25 in the univariate analysis were included in the multivariable logistic regression model. Given the limited sample size, multicollinearity between anthropometric variables was considered. The results revealed that a significant risk factor for the occurrence of significant PR was the z score of the PVA minimum diameter (p = 0.001) with an odds ratio (OR) of 0.52 (95% CI: 0.35–0.77) (Table 3 ). Each one-unit increase in the minimum PVA z-score reduced the odds of significant PR by approximately 48%. Table 3 Logistic regression analysis of risk factors associated with pulmonary regurgitation Variables Multivariate P OR CI (95%) Gender 0.215 1.78 0.72–4.44 Age 0.679 0.99 0.99–1.01 PVA z score Maximum diameter 0.376 0.77 0.43–1.37 Minimum diameter 0.001 0.52 0.35–0.77 4. Discussion Patients with a low PVA z-score generally have a greater risk of developing early significant PR after ToF repair. 5 , 7 In patients with a small PVA, the use of a TAP is often required to enlarge the annulus to approximate the ideal annular size according to age and body weight, thereby adequately relieving pulmonary stenosis. However, annular incisions during the TAP procedure render the pulmonary valve incompetent, resulting in significant PR. Consequently, patients who undergo TAP are at high risk of developing significant PR. 12 Preoperative PVA z scores have consistently been reported to be greater in patients undergoing valve-sparing procedures than in those requiring TAP. 13 Moreover, even in patients without TAP, a small PVA may lead to PR through other mechanisms. To preserve the pulmonary valve in the setting of a markedly small annulus, extensive commissurotomy is often performed, followed by infundibulectomy through a relatively small PVA without right ventriculotomy. Excessive commissurotomy may extend beyond the medial layer, splitting the annulus and causing partial detachment of the pulmonary valve leaflets at the commissural regions. When combined with subclinical aneurysmal dilatation of the RVOT, this condition may result in immediate postoperative significant PR, particularly after the resolution of the restrictive right ventricular physiology phase. 14 The outcome of ToF repair is determined by effective ventricular septal defect (VSD) closure and adequate relief of RVOT obstruction. While TAP placement is performed to eliminate RVOT obstruction, it may compromise the integrity of the pulmonary annulus. Although the risk of sudden cardiac death (SCD) has been associated with pulmonary valve incompetence, QRS prolongation has been shown to be the strongest predictor of ventricular arrhythmias. Evidence suggests that pulmonary stenosis, including residual RVOT obstruction, leads to right ventricular hypertrophy and plays a greater role in QRS prolongation and SCD than does PR. Using excessively low PVA z score thresholds as the sole criterion for valve-sparing repair may result in residual RVOT obstruction, ultimately increasing the risk of late postoperative complications in patients after ToF repair. 15 Therefore, PVA z scores should be used judiciously to guide surgical strategies, balancing the avoidance of TAP placement against the risk of residual RVOT obstruction from overly aggressive valve-sparing repair. To our knowledge, this study is among the first in Southeast Asia to evaluate MSCT-derived PVA z scores for predicting postoperative outcomes after ToF repair, providing population-specific data that may complement existing echocardiography-based literature. Despite good technical performance, limited echocardiographic image quality often results in incomplete visualization of the entire RVOT. Three-dimensional evaluation of the RVOT has demonstrated that the RVOT is more oval than circular. Cardiac MSCT is a more advanced, higher-resolution imaging modality that allows more accurate measurements and enables three-dimensional assessment with superior visualization of the annular plane and its configuration. 8 Early identification of patients at high risk for PR may guide intraoperative decision making, including maximal leaflet preservation, the use of a monocusp valve during TAP, or the selection of a valved right ventricle-to-pulmonary artery conduit. In the early postoperative period, closer hemodynamic monitoring and cautious optimization of ventilation and right ventricular preload may be warranted because the presence of a PR as a residual lesion increases the risk of prolonged postoperative mechanical ventilation. 16 During mid- to long-term follow up, early prediction of PR may facilitate tighter surveillance intervals, earlier use of cardiac magnetic resonance imaging, and optimal timing of pulmonary valve intervention. In patients with significant PR, pulmonary valve replacement (PVR) has been shown to improve functional class and reduce right ventricle volume, thereby lowering the risk of arrhythmias and heart failure. 17 In this study, the minimum PVA diameter z score was associated with the occurrence of PR, underscoring its clinical relevance for early risk stratification. Nevertheless, the moderate AUC indicates that annular size alone cannot fully predict postoperative PR, emphasizing the multifactorial nature of this outcome. For example, in a study by Hoashi et al., bicuspid valve morphology abnormalities were also identified as risk factors for progression from moderate to severe PR in patients who underwent valve-sparing ToF repair. 14 Incomplete intraoperative data on pulmonary valve morphology in our study precluded its analysis despite its clinical relevance. This study was conducted at a single center with a retrospective design. Prospective studies with longer monitoring periods are needed to assess the long-term impact of PVA z scores on significant PR more accurately. The PVA z scores were calculated using the formula proposed by Soszyn et al., which is based on a non-Indonesian population and may limit comparability with other studies. 5. Conclusion The z score of the PVA minimum diameter measured by preoperative MSCT was associated with early significant PR after ToF repair. A cut-off of -2.5 showed high specificity and may support early risk stratification, although surgical decision-making and postoperative monitoring should incorporate additional clinical and intraoperative considerations. Abbreviations AUC Area under the curve BSA Body surface area CI Confidence interval ICC Intraclass correlation coeficient MPR Multiplanar reformation MSCT Multislice computed tomography OR Odd ratio PA Pulmonary artery PHT Pressure half time PR Pulmonary regurgitation PVA Pulmonary valve annulus ROC Receiver operating characteristic RVOT Right ventricular outflow tract SCD Sudden cardiac death SD Standard deviation TAP Transannular patch ToF Tetralogy of Fallot VSD Ventricular septal defect Declarations Ethics approval and consent to participate Ethical approval was obtained retrospectively from the Committee on Institutional Review Board/Health Research Ethics of National Cardiac Center Harapan Kita Hospital (approval number DP.04.03/KEP164/EC102/2025). Given the retrospective nature of the study, the requirement for informed consent was waived. Consent for publication Not applicable. Availability of data and materials The datasets generated and/or analyzed during this study are available from the corresponding author upon reasonable request. Competing interests The authors declare that they have no competing interests and received no financial support for this study Funding This research did not receive any specific grants from funding agencies in the public, commercial or not-for-profit sectors. Authors contributions Pribadi W. Busro (PWB), Ahmad Adityawarman (AA), Suprayitno Wardoyo (SW), and Oktavia Lilyasari (OL) involved in concept/design and drafted the paper. PWB, AA, SW, OL and Retno Wibawanti (RW) defined analysis method and involved in data analysis and interpretation. AA collected the data. OL and Olfi Lelya (OLY) contributed in assessment of cardiac MSCT imaging. Damba DA Sakti (DDS) and Yovi Kurniawati (YK) supported the echocardiographic imaging assessment. PWB, SW, OL, and RW performed critical revision. All authors approved the final version of the manuscript and take responsibility for the work as a whole. Acknowledgements The authors thank James Klemens Phieter Phie for support in MSCT assessment and patient data collection, and those who participated in this study for their dedicated work in data analysis and data entry Generative AI and AI-Assisted Technologies in the Writing Process The authors acknowledge that Artificial Intelligence (AI) tools were only used to assist in language editing and manuscript refinement. No AI tools were used to generate, modify, or interpret the scientific content, data analyses, or conclusions presented in this manuscript. The authors remain fully responsible for the integrity and originally of the work. References Dib N, Chauvette V, Diop MS, Bouhout I, Hadid M, Vô C. Tetralogy of Fallot in low-and middle-income countries. CJC Pediatr Congenit Hear Dis. 2024;3(2):67–73. Lee MGY, Yao JV, Binny S, Larobina M, Skillington P, Grigg LE, et al. Long-term outcome of adult survivors of tetralogy of Fallot. Int J Cardiol Congenit Hear Dis. 2021;4:100147. Apandi PR, Sukardi R, Djer MM, Yanuarso PB, Wardoyo S. Risk factors for severe pulmonary regurgitation after repair of tetralogy of Fallot with transannular patch. Cardiol Young. 2020;30(12):1917–22. Aguirrezabalaga JA, Guisasola JS, Méndez RD, Veizaga AE, Panizo DH. Pulmonary regurgitation after repaired tetralogy of Fallot: surgical versus percutaneous treatment. Ann Transl Med. 2020;8(15). Guariento A, Schiena CA, Cattapan C, Avesani M, Doulamis IP, Padalino MA et al. Pulmonary valve preservation during tetralogy of Fallot repair: midterm functional outcomes and risk factors for pulmonary regurgitation. Eur J Cardio-Thoracic Surg. 2022;62(2). Khan MA, Hasan KA, Salam AA, Azad QA, Siddiqua SS, Islam MZ. Total correction of tetralogy of Fallot: effect of transannular patch on early outcome. Cardiovasc J. 2018;10(2):194–200. Li MQ, Ding WH, Jin M, Wang ZY, Gu Y, Ye WQ, et al. Pulmonary valve annular and right ventricular outflow tract size as predictions values for moderate to severe pulmonary regurgitation after repaired tetralogy of Fallot. Echocardiography. 2020;37(10):1627–33. Soszyn N, Shorofsky M, Franco SR, JE M Z. Computed tomography-derived normative values and z-scores of the pulmonary valve annulus and sino-tubular junction in the pediatric population. J Cardiovasc Comput Tomogr. 2024;18(5):489–93. Berendoncks A, Van GR, Van, Mcghie J, Cuypers JAAE, Bogers AJJC. Echocardiographic parameters of severe pulmonary regurgitation after surgical repair of tetralogy of Fallot. Congenit Heart Dis. 2019;14:628–37. Zoghbi WA, Adams D, Bonow RO, Enriquez-sarano M, Foster E, Grayburn PA, et al. Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the american society of echocardiography developed in collaboration with the society for cardiovascular magnetic resonance. J Am Soc Echocardiogr. 2017;30(4):303–71. Senthilnathan S, Dragulescu A, Mertens L. Pulmonary regurgitation after tetralogy of Fallot repair: a diagnostic and therapeutic challenge. J Cardiovasc Echogr. 2013;23(1):1–9. Jiang X, Liu J, Peng B, Zhang H, Li S, Yan J, et al. Impact of annulus–sparing on surgical adequacy of pulmonary valve in complete repair of tetralogy of Fallot with right ventricular outflow tract incision. Pediatr Cardiol. 2021;42:379–88. Sitanggang JS, Purba S, Fakhri D, Busro PW, Rahmat B, Utomo P et al. Meta-analysis and systematic review of pulmonary valve annulus z-score as a predictor of valve preservation in tetralogy of fallot right ventricular outflow tract reconstruction. medRxiv. 2025;1–27. Hoashi T, Kagisaki K, Meng Y, Sakaguchi H. Long-term outcomes after definitive repair for tetralogy of Fallot with preservation of the pulmonary valve annulus. J Thorac Cardiovasc Surg. 2014;148(3):802–9. Awori MN, Mehta NP, Mitema FO, Kebba N. Optimal use of z scores to preserve the pulmonary valve annulus during repair of tetralogy of Fallot. World J Pediatr Congenit Hear Surg. 2018;9(3):285–8. Kesumarini D, Widyastuti Y, Boom CE, Dinarti LK. Risk factors associated with prolonged mechanical ventilation and length of stay after repair of tetralogy of Fallot. World J Pediatr Congenit Hear Surg. 2024;15(1):81–8. Leonardi B, Calvieri C, Perrone MA, Rocco A, Carotti A, Caputo M. Risk factors of right ventricular dysfunction and adverse cardiac events in patients with repaired tetralogy of Fallot. Int J Environ Res Public Health. 2021;18(19):10549. Additional Declarations No competing interests reported. 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Indonesia","correspondingAuthor":false,"prefix":"","firstName":"Oktavia","middleName":"","lastName":"Lilyasari","suffix":""}],"badges":[],"createdAt":"2026-02-05 08:08:55","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8793939/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8793939/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104874792,"identity":"3cc8a904-0300-4fd8-a129-2ecc161ef4a2","added_by":"auto","created_at":"2026-03-18 08:33:20","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":17102,"visible":true,"origin":"","legend":"\u003cp\u003eROC curve of the preoperative PVA maximum diameter z score for predicting PR\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8793939/v1/f2a134667aeabdb6cee58fbb.png"},{"id":104874791,"identity":"072c1417-834a-4611-8c77-6f8b527409ef","added_by":"auto","created_at":"2026-03-18 08:33:20","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":13165,"visible":true,"origin":"","legend":"\u003cp\u003eROC curve of the preoperative PVA minimum diameter z score for predicting PR\u003c/p\u003e","description":"","filename":"floatimage2.png","url":"https://assets-eu.researchsquare.com/files/rs-8793939/v1/048936459ab86becf594929b.png"},{"id":104874793,"identity":"afe548df-f131-4dca-8625-25d4a6855c73","added_by":"auto","created_at":"2026-03-18 08:33:25","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":660546,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8793939/v1/7e467be1-f645-401a-b4bf-5e06e4330716.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Preoperative Pulmonary Valve Annulus Diameter Z Score as a Predictor of Pulmonary Regurgitation after Tetralogy of Fallot Repair: A Retrospective Cohort Study","fulltext":[{"header":"1. Background","content":"\u003cp\u003eTetralogy of Fallot (ToF) is the most common form of cyanotic congenital heart disease, accounting for approximately 3\u0026ndash;5% of all congenital heart diseases with an incidence of 0,28\u0026thinsp;\u0026minus;\u0026thinsp;0,34 per 1000 live births.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e The survival rate for patients who undergo surgical repair of ToF is as high as 95% at the age of 40 years.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e Pulmonary regurgitation (PR) is the most frequent complication after ToF repair surgery in the middle- and long-term. Chronic PR may lead to right ventricular overload, ventricular dysfunction, arrhythmia, and other cardiovascular complications including sudden death such that it influences the overall prognosis.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e Moderate-to-severe PR in the early postoperative period has been shown to be a risk factor for the development of midterm PR; therefore, early detection is important.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn some ToF patients, right ventricular outflow tract stenosis can be released optimally with transannular patch (TAP) insertion, but this technique is the main risk factor for consequent PR.\u003csup\u003e6\u003c/sup\u003e The size of the pulmonary valve annulus (PVA) is the main predictor of the TAP requirement, and a low PVA z score was associated with the incidence of postoperative PR in some studies.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e The PVA z-score, which is a calculation used to normalize the PVA size to the patient\u0026rsquo;s body surface area, is a more informative calculation than the absolute measurement alone. Most previous studies relied on echocardiographic measurements assuming a circular annulus, potentially underestimating annular asymmetry.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Data on the use of multislice computed tomography (MSCT)-derived PVA diameter as a predictor of early postoperative PR limited.\u003c/p\u003e \u003cp\u003eThis study aimed to assess the role of the preoperative PVA diameter z-score, measured via cardiac MSCT, in the prediction of PR after ToF repair at our center, which is a national cardiac surgery referral center and has unique population characteristics compared with those reported abroad. Determining the z score cut-off for predicting postoperative PR will provide important contributions to both surgical strategy planning and follow-up after surgery including long-term patient monitoring.\u003c/p\u003e"},{"header":"2. Patients and methods","content":"\u003cp\u003e \u003cem\u003eStudy design and definitions\u003c/em\u003e \u003c/p\u003e \u003cp\u003eThis retrospective cohort study enrolled patients underwent ToF repair surgery from January 2023-December 2024 at the National Cardiac Center Harapan Kita. Ethical approval was obtained retrospectively from the Committee on Institutional Review Board/Health Research Ethics of National Cardiac Center Harapan Kita Hospital on October 6, 2025 under approval number DP.04.03/KEP164/EC102/2025.\u003c/p\u003e \u003cp\u003eA total of 101 patients were included in this study. The subjects were patients aged\u0026thinsp;\u0026lt;\u0026thinsp;18 years without complex congenital disorders such as ToF patients with atrioventricular septal defects, anomalous pulmonary vein drainage, absence of the pulmonary valve, pulmonary atresia, and coronary artery anomalies. We also excluded patients who had undergone systemic to pulmonary artery shunt surgery or palliative procedures such as modified BTT shunt, central shunt, PDA stenting, and right ventricular outflow tract (RVOT) stenting before ToF repair surgery. Research data, including preoperative MSCT and postoperative echocardiography data, were obtained from patient medical records.\u003c/p\u003e \u003cp\u003eThe PVA diameter was measured retrospectively from preoperative cardiac MSCT recordings. To ensure accurate PVA measurement, multiplanar reformation (MPR) was performed at the annular level to obtain the most ideal circular image, and then the minimum and maximum diameters were measured.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e The obtained minimum and maximum diameters were then substituted into the z score formula.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e Body surface area (BSA), which is incorporated into the z-score calculation, was determined using the Haycock formula.\u003c/p\u003e \u003cp\u003eThe PR assessment was based on transthoracic echocardiography performed during the outpatient visit within 45 days after the operation via a parasternal short-axis view. Echocardiography recordings were considered adequate if they provided a sufficient field of view and good image quality.\u003c/p\u003e \u003cp\u003eThe severity of PR was divided into two categories: significant and not significant. Not significant PR is a PR with a mild or lower degree, where the criteria for mild PR are the presence of diastolic reversal flow in the main PA, a small and narrow jet (\u0026lt;\u0026thinsp;10 mm), and a PR/RVOT jet width ratio of \u0026lt;\u0026thinsp;0.2. A significant PR is a moderate PR or greater. The criteria for moderate PR are diastolic reversal flow at the pulmonary artery (PA) bifurcation, an intermediate jet size, and a PR/RVOT jet width ratio of 0.2\u0026ndash;0.5. The criteria for severe PR are diastolic reversal flow in the PA branches, a wide jet size on color Doppler with varying penetration depths, a PR/RVOT jet width ratio of \u0026gt;\u0026thinsp;0.5, dense jet density and contour with early diastolic flow termination, and a pressure half time (PHT) of \u0026lt;\u0026thinsp;100 ms.\u003csup\u003e9\u0026ndash;11\u003c/sup\u003e\u003c/p\u003e \u003cp\u003e \u003cem\u003eStatistical analysis\u003c/em\u003e \u003c/p\u003e \u003cp\u003eData analysis was performed via SPSS for Windows (version 27, 2020). Patients were divided into two groups on the basis of postoperative PR: those with significant PR and those with no significant PR. Quantitative variables are displayed as the mean\u0026thinsp;\u0026plusmn;\u0026thinsp;standard deviation (SD) or median (interquartile range). Categorical data are displayed as proportions (%). Bivariate analysis of the relationships between quantitative variables and categorical variables was performed via the unpaired t test or Mann-Whitney test. The chi-square or Fisher\u0026rsquo;s exact test was used to analyse the relationships between categorical variables of groups. Variables with a significant p value\u0026thinsp;\u0026lt;\u0026thinsp;0.25 in the bivariate analysis were included in the multivariate analysis via logistic regression. Results with a p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 were considered statistically significant. The cut-off value of the PVA z score for predicting PR was obtained via a receiver operating characteristic (ROC) curve.\u003c/p\u003e"},{"header":"3. Results","content":"\u003cp\u003eA total of 101 patients who met the criteria were included in the study. The median age at surgery was 38 months, with a range of 7-162 months. The median weight was 11.16 kg, with a range of 5.5\u0026ndash;39 kg. Other patient characteristics are shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. The average z scores of the preoperative PVA maximum and minimum diameters were \u0026minus;\u0026thinsp;2.22\u0026thinsp;\u0026plusmn;\u0026thinsp;1.23 and \u0026minus;\u0026thinsp;1.88\u0026thinsp;\u0026plusmn;\u0026thinsp;1.24, respectively. TAP insertion was performed in the majority of patients (64.4%). An echocardiography study after ToF repair surgery revealed that significant PR occurred in 68.3% of patients.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eSubject characteristics\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"2\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal n\u0026thinsp;=\u0026thinsp;101\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at surgery (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (7-162)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e63 (62.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e38 (37.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e11.16 (5.50\u0026ndash;39.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e88 (61.00-162.00)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBSA (m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.54 (0.33\u0026ndash;1.31)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMcGoon ratio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.10 (1.32\u0026ndash;3.30)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePVA z score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaximal diameter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-2.22\u0026thinsp;\u0026plusmn;\u0026thinsp;1.23\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMinimal diameter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.88\u0026thinsp;\u0026plusmn;\u0026thinsp;1.24\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e36 (35.6%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e65 (64.4%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSignificant pulmonary regurgitation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e32 (31.7%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69 (68.3%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003ePVA diameters were independently measured by two observers via MSCT images and interobserver reliability was assessed via the intraclass correlation coefficient (ICC). Excellent agreement was observed for the maximum PVA diameter (ICC\u0026thinsp;=\u0026thinsp;0.939; 95% CI: 0.881\u0026ndash;0.969; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001); Cronbach\u0026rsquo;s alpha\u0026thinsp;=\u0026thinsp;0.971) and good agreement was observed for the minimum PVA diameter (ICC\u0026thinsp;=\u0026thinsp;0.898; 95% CI: 0.808\u0026ndash;0.947; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001; Cronbach\u0026rsquo;s alpha\u0026thinsp;=\u0026thinsp;0.945). Interobserver agreement for postoperative PR assessment via echocardiography was good (Kappa\u0026thinsp;=\u0026thinsp;0.727; p\u0026thinsp;=\u0026thinsp;0.001), whereas intraobserver agreement was perfect (Kappa\u0026thinsp;=\u0026thinsp;1.0; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eAccording to univariate analysis, the PVA z score was significantly associated with the incidence of significant PR (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), with p\u0026thinsp;\u0026lt;\u0026thinsp;0.001 for the minimum diameter and p\u0026thinsp;=\u0026thinsp;0.001 for the maximum diameter. Patients with significant PR had lower mean z scores of the maximum PVA diameter (-2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17) and lower mean z scores of the minimum PVA diameter (-2.17\u0026thinsp;\u0026plusmn;\u0026thinsp;1.18).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eRisk factor analysis for pulmonary regurgitation after ToF repair\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eNot significant PR\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;32)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSignificant PR\u003c/p\u003e \u003cp\u003e(n\u0026thinsp;=\u0026thinsp;69)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eP\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge at surgery (months)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e56.5 (7-139)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34 (8-162)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.140\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e17 (27%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e46 (73%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\" morerows=\"1\" rowspan=\"2\"\u003e \u003cp\u003e0.191\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e15 (39.5%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e23 (60.5%)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eWeight (kg)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e12 (6.6\u0026ndash;28)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e10.8 (5.5\u0026ndash;39)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.193\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHeight (cm)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e99 (67\u0026ndash;129)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e85 (61\u0026ndash;162)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.122\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eBSA (m\u003csup\u003e2\u003c/sup\u003e)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e0.57 (0.35\u0026ndash;0.99)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.51 (0.33\u0026ndash;1.31)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.167\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMcGoon ratio\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e2.18 (1.57\u0026ndash;3.3)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e2.1 (1.32\u0026ndash;3.2)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e0.876\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePVA z-score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaximal diameter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.65\u0026thinsp;\u0026plusmn;\u0026thinsp;1.19\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u0026minus;\u0026thinsp;2.5\u0026thinsp;\u0026plusmn;\u0026thinsp;1.17\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMinimal diameter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e-1.25\u0026thinsp;\u0026plusmn;\u0026thinsp;1.15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e-2.17\u0026thinsp;\u0026plusmn;\u0026thinsp;1.18\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eROC analysis was performed for the PVA z score parameters to predict the occurrence of significant PRs. Both the maximum and minimum PVA diameter z scores demonstrated moderate discriminative ability for predicting significant pulmonary regurgitation, with area under the curve (AUC) values of 0.695 and 0.701, respectively. A cut-off value of -2.1 for the z-score of the PVA maximum diameter (95% CI: 0.59\u0026ndash;0.81) yielded a sensitivity of 66.7% and a specificity of 68.7% (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). A cut-off value of -2,5 for the z score of the PVA minimum diameter (95% CI: 0.60\u0026ndash;0.81) yielded a sensitivity of 42% and a specificity of 90.6% (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), demonstrating high specificity but limited sensitivity, indicating its utility in ruling in, rather than ruling out, early PR.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eMultivariate analysis was performed via binary logistic regression with the backwards LR method. Risk factors with P values\u0026thinsp;\u0026lt;\u0026thinsp;0.25 in the univariate analysis were included in the multivariable logistic regression model. Given the limited sample size, multicollinearity between anthropometric variables was considered. The results revealed that a significant risk factor for the occurrence of significant PR was the z score of the PVA minimum diameter (p\u0026thinsp;=\u0026thinsp;0.001) with an odds ratio (OR) of 0.52 (95% CI: 0.35\u0026ndash;0.77) (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Each one-unit increase in the minimum PVA z-score reduced the odds of significant PR by approximately 48%.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eLogistic regression analysis of risk factors associated with pulmonary regurgitation\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"8\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colspan=\"2\" morerows=\"1\" nameend=\"c2\" namest=\"c1\" rowspan=\"2\"\u003e \u003cp\u003eVariables\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"5\" nameend=\"c7\" namest=\"c3\"\u003e \u003cp\u003eMultivariate\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003e\u003cb\u003eP\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e\u003cb\u003eOR\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c7\"\u003e \u003cp\u003e\u003cb\u003eCI (95%)\u003c/b\u003e\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eGender\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.215\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e1.78\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.72\u0026ndash;4.44\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003eAge\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.679\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e \u003cp\u003e0.99\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e \u003cp\u003e0.99\u0026ndash;1.01\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e \u003cp\u003ePVA z score\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c6\" namest=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e \u003ctd align=\"left\" colspan=\"1\" nameend=\"c8\" namest=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eMaximum diameter\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e0.376\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e0.77\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e0.43\u0026ndash;1.37\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e\u003cb\u003eMinimum diameter\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c4\" namest=\"c2\"\u003e \u003cp\u003e\u003cb\u003e0.001\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c5\"\u003e \u003cp\u003e\u003cb\u003e0.52\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colspan=\"3\" nameend=\"c8\" namest=\"c6\"\u003e \u003cp\u003e\u003cb\u003e0.35\u0026ndash;0.77\u003c/b\u003e\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"4. Discussion","content":"\u003cp\u003ePatients with a low PVA z-score generally have a greater risk of developing early significant PR after ToF repair.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e In patients with a small PVA, the use of a TAP is often required to enlarge the annulus to approximate the ideal annular size according to age and body weight, thereby adequately relieving pulmonary stenosis. However, annular incisions during the TAP procedure render the pulmonary valve incompetent, resulting in significant PR. Consequently, patients who undergo TAP are at high risk of developing significant PR.\u003csup\u003e12\u003c/sup\u003e Preoperative PVA z scores have consistently been reported to be greater in patients undergoing valve-sparing procedures than in those requiring TAP.\u003csup\u003e\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eMoreover, even in patients without TAP, a small PVA may lead to PR through other mechanisms. To preserve the pulmonary valve in the setting of a markedly small annulus, extensive commissurotomy is often performed, followed by infundibulectomy through a relatively small PVA without right ventriculotomy. Excessive commissurotomy may extend beyond the medial layer, splitting the annulus and causing partial detachment of the pulmonary valve leaflets at the commissural regions. When combined with subclinical aneurysmal dilatation of the RVOT, this condition may result in immediate postoperative significant PR, particularly after the resolution of the restrictive right ventricular physiology phase.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eThe outcome of ToF repair is determined by effective ventricular septal defect (VSD) closure and adequate relief of RVOT obstruction. While TAP placement is performed to eliminate RVOT obstruction, it may compromise the integrity of the pulmonary annulus. Although the risk of sudden cardiac death (SCD) has been associated with pulmonary valve incompetence, QRS prolongation has been shown to be the strongest predictor of ventricular arrhythmias. Evidence suggests that pulmonary stenosis, including residual RVOT obstruction, leads to right ventricular hypertrophy and plays a greater role in QRS prolongation and SCD than does PR. Using excessively low PVA z score thresholds as the sole criterion for valve-sparing repair may result in residual RVOT obstruction, ultimately increasing the risk of late postoperative complications in patients after ToF repair.\u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e Therefore, PVA z scores should be used judiciously to guide surgical strategies, balancing the avoidance of TAP placement against the risk of residual RVOT obstruction from overly aggressive valve-sparing repair.\u003c/p\u003e \u003cp\u003eTo our knowledge, this study is among the first in Southeast Asia to evaluate MSCT-derived PVA z scores for predicting postoperative outcomes after ToF repair, providing population-specific data that may complement existing echocardiography-based literature. Despite good technical performance, limited echocardiographic image quality often results in incomplete visualization of the entire RVOT. Three-dimensional evaluation of the RVOT has demonstrated that the RVOT is more oval than circular. Cardiac MSCT is a more advanced, higher-resolution imaging modality that allows more accurate measurements and enables three-dimensional assessment with superior visualization of the annular plane and its configuration.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eEarly identification of patients at high risk for PR may guide intraoperative decision making, including maximal leaflet preservation, the use of a monocusp valve during TAP, or the selection of a valved right ventricle-to-pulmonary artery conduit. In the early postoperative period, closer hemodynamic monitoring and cautious optimization of ventilation and right ventricular preload may be warranted because the presence of a PR as a residual lesion increases the risk of prolonged postoperative mechanical ventilation.\u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e During mid- to long-term follow up, early prediction of PR may facilitate tighter surveillance intervals, earlier use of cardiac magnetic resonance imaging, and optimal timing of pulmonary valve intervention. In patients with significant PR, pulmonary valve replacement (PVR) has been shown to improve functional class and reduce right ventricle volume, thereby lowering the risk of arrhythmias and heart failure.\u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e \u003cp\u003eIn this study, the minimum PVA diameter z score was associated with the occurrence of PR, underscoring its clinical relevance for early risk stratification. Nevertheless, the moderate AUC indicates that annular size alone cannot fully predict postoperative PR, emphasizing the multifactorial nature of this outcome. For example, in a study by Hoashi et al., bicuspid valve morphology abnormalities were also identified as risk factors for progression from moderate to severe PR in patients who underwent valve-sparing ToF repair.\u003csup\u003e\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u003c/sup\u003e Incomplete intraoperative data on pulmonary valve morphology in our study precluded its analysis despite its clinical relevance.\u003c/p\u003e \u003cp\u003eThis study was conducted at a single center with a retrospective design. Prospective studies with longer monitoring periods are needed to assess the long-term impact of PVA z scores on significant PR more accurately. The PVA z scores were calculated using the formula proposed by Soszyn et al., which is based on a non-Indonesian population and may limit comparability with other studies.\u003c/p\u003e"},{"header":"5. Conclusion","content":"\u003cp\u003eThe z score of the PVA minimum diameter measured by preoperative MSCT was associated with early significant PR after ToF repair. A cut-off of -2.5 showed high specificity and may support early risk stratification, although surgical decision-making and postoperative monitoring should incorporate additional clinical and intraoperative considerations.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003e\u003cb\u003eAUC\u003c/b\u003e Area under the curve\u003c/p\u003e\u003cp\u003e\u003cb\u003eBSA\u003c/b\u003e Body surface area\u003c/p\u003e\u003cp\u003e\u003cb\u003eCI\u003c/b\u003e Confidence interval\u003c/p\u003e\u003cp\u003e\u003cb\u003eICC\u003c/b\u003e Intraclass correlation coeficient\u003c/p\u003e\u003cp\u003e\u003cb\u003eMPR\u003c/b\u003e Multiplanar reformation\u003c/p\u003e\u003cp\u003e\u003cb\u003eMSCT\u003c/b\u003e Multislice computed tomography\u003c/p\u003e\u003cp\u003e\u003cb\u003eOR\u003c/b\u003e Odd ratio\u003c/p\u003e\u003cp\u003e\u003cb\u003ePA\u003c/b\u003e Pulmonary artery\u003c/p\u003e\u003cp\u003e\u003cb\u003ePHT\u003c/b\u003e Pressure half time\u003c/p\u003e\u003cp\u003e\u003cb\u003ePR\u003c/b\u003e Pulmonary regurgitation\u003c/p\u003e\u003cp\u003ePVA Pulmonary valve annulus\u003c/p\u003e\u003cp\u003e\u003cb\u003eROC\u003c/b\u003e Receiver operating characteristic\u003c/p\u003e\u003cp\u003e\u003cb\u003eRVOT\u003c/b\u003e Right ventricular outflow tract\u003c/p\u003e\u003cp\u003e\u003cb\u003eSCD\u003c/b\u003e Sudden cardiac death\u003c/p\u003e\u003cp\u003e\u003cb\u003eSD\u003c/b\u003e Standard deviation\u003c/p\u003e\u003cp\u003e\u003cb\u003eTAP\u003c/b\u003e Transannular patch\u003c/p\u003e\u003cp\u003e\u003cb\u003eToF\u003c/b\u003e Tetralogy of Fallot\u003c/p\u003e\u003cp\u003e\u003cb\u003eVSD\u003c/b\u003e Ventricular septal defect\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was obtained retrospectively from the Committee on Institutional Review Board/Health Research Ethics of National Cardiac Center Harapan Kita Hospital (approval number DP.04.03/KEP164/EC102/2025). Given the retrospective nature of the study, the requirement for informed consent was waived.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe datasets generated and/or analyzed during this study are available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests and received no financial support for this study\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research did not receive any specific grants from funding agencies in the public, commercial or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003ePribadi W. Busro (PWB), Ahmad Adityawarman (AA), Suprayitno Wardoyo (SW), and Oktavia Lilyasari (OL) involved in concept/design and drafted the paper. PWB, AA, SW, OL and Retno Wibawanti (RW) defined analysis method and involved in data analysis and interpretation. AA collected the data. OL and Olfi Lelya (OLY) contributed in assessment of cardiac MSCT imaging. Damba DA Sakti (DDS) and Yovi Kurniawati (YK) supported the echocardiographic imaging assessment. PWB, SW, OL, and RW performed critical revision. All authors approved the final version of the manuscript and take responsibility for the work as a whole.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors thank James Klemens Phieter Phie for support in MSCT assessment and patient data collection, and those who participated in this study for their dedicated work in data analysis and data entry\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGenerative AI and AI-Assisted Technologies in the Writing Process\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors acknowledge that Artificial Intelligence (AI) tools were only used to assist in language editing and manuscript refinement. No AI tools were used to generate, modify, or interpret the scientific content, data analyses, or conclusions presented in this manuscript. The authors remain fully responsible for the integrity and originally of the work.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eDib N, Chauvette V, Diop MS, Bouhout I, Hadid M, V\u0026ocirc; C. Tetralogy of Fallot in low-and middle-income countries. CJC Pediatr Congenit Hear Dis. 2024;3(2):67\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLee MGY, Yao JV, Binny S, Larobina M, Skillington P, Grigg LE, et al. Long-term outcome of adult survivors of tetralogy of Fallot. Int J Cardiol Congenit Hear Dis. 2021;4:100147.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eApandi PR, Sukardi R, Djer MM, Yanuarso PB, Wardoyo S. Risk factors for severe pulmonary regurgitation after repair of tetralogy of Fallot with transannular patch. Cardiol Young. 2020;30(12):1917\u0026ndash;22.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAguirrezabalaga JA, Guisasola JS, M\u0026eacute;ndez RD, Veizaga AE, Panizo DH. Pulmonary regurgitation after repaired tetralogy of Fallot: surgical versus percutaneous treatment. Ann Transl Med. 2020;8(15).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGuariento A, Schiena CA, Cattapan C, Avesani M, Doulamis IP, Padalino MA et al. Pulmonary valve preservation during tetralogy of Fallot repair: midterm functional outcomes and risk factors for pulmonary regurgitation. Eur J Cardio-Thoracic Surg. 2022;62(2).\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKhan MA, Hasan KA, Salam AA, Azad QA, Siddiqua SS, Islam MZ. Total correction of tetralogy of Fallot: effect of transannular patch on early outcome. Cardiovasc J. 2018;10(2):194\u0026ndash;200.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLi MQ, Ding WH, Jin M, Wang ZY, Gu Y, Ye WQ, et al. Pulmonary valve annular and right ventricular outflow tract size as predictions values for moderate to severe pulmonary regurgitation after repaired tetralogy of Fallot. Echocardiography. 2020;37(10):1627\u0026ndash;33.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSoszyn N, Shorofsky M, Franco SR, JE M Z. Computed tomography-derived normative values and z-scores of the pulmonary valve annulus and sino-tubular junction in the pediatric population. J Cardiovasc Comput Tomogr. 2024;18(5):489\u0026ndash;93.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBerendoncks A, Van GR, Van, Mcghie J, Cuypers JAAE, Bogers AJJC. Echocardiographic parameters of severe pulmonary regurgitation after surgical repair of tetralogy of Fallot. Congenit Heart Dis. 2019;14:628\u0026ndash;37.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eZoghbi WA, Adams D, Bonow RO, Enriquez-sarano M, Foster E, Grayburn PA, et al. Recommendations for noninvasive evaluation of native valvular regurgitation: a report from the american society of echocardiography developed in collaboration with the society for cardiovascular magnetic resonance. J Am Soc Echocardiogr. 2017;30(4):303\u0026ndash;71.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSenthilnathan S, Dragulescu A, Mertens L. Pulmonary regurgitation after tetralogy of Fallot repair: a diagnostic and therapeutic challenge. J Cardiovasc Echogr. 2013;23(1):1\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eJiang X, Liu J, Peng B, Zhang H, Li S, Yan J, et al. Impact of annulus\u0026ndash;sparing on surgical adequacy of pulmonary valve in complete repair of tetralogy of Fallot with right ventricular outflow tract incision. Pediatr Cardiol. 2021;42:379\u0026ndash;88.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eSitanggang JS, Purba S, Fakhri D, Busro PW, Rahmat B, Utomo P et al. Meta-analysis and systematic review of pulmonary valve annulus z-score as a predictor of valve preservation in tetralogy of fallot right ventricular outflow tract reconstruction. medRxiv. 2025;1\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHoashi T, Kagisaki K, Meng Y, Sakaguchi H. Long-term outcomes after definitive repair for tetralogy of Fallot with preservation of the pulmonary valve annulus. J Thorac Cardiovasc Surg. 2014;148(3):802\u0026ndash;9.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAwori MN, Mehta NP, Mitema FO, Kebba N. Optimal use of z scores to preserve the pulmonary valve annulus during repair of tetralogy of Fallot. World J Pediatr Congenit Hear Surg. 2018;9(3):285\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eKesumarini D, Widyastuti Y, Boom CE, Dinarti LK. Risk factors associated with prolonged mechanical ventilation and length of stay after repair of tetralogy of Fallot. World J Pediatr Congenit Hear Surg. 2024;15(1):81\u0026ndash;8.\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLeonardi B, Calvieri C, Perrone MA, Rocco A, Carotti A, Caputo M. Risk factors of right ventricular dysfunction and adverse cardiac events in patients with repaired tetralogy of Fallot. Int J Environ Res Public Health. 2021;18(19):10549.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Tetralogy of Fallot, pulmonary valve annulus, pulmonary annulus z score, pulmonary regurgitation, cardiac surgery","lastPublishedDoi":"10.21203/rs.3.rs-8793939/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8793939/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eTetralogy of Fallot (ToF) is the most common cause of cyanotic congenital heart disease and pulmonary regurgitation (PR) remains the most frequent complication after ToF repair, affecting a patient\u0026rsquo;s long-term prognosis. The preoperative z score of the pulmonary valve annulus (PVA) has been shown to be associated with an increased risk of significant PR after ToF repair; however, the optimal cut-off value varies among studies and has not been investigated in the Indonesian population. This study aimed to determine the predictive value of the preoperative PVA z score diameter for the occurrence of PR after ToF repair.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective cohort study was conducted using secondary data from pediatric patients who underwent ToF repair at the National Cardiac Center Harapan Kita between January 2023 and December 2024. The preoperative PVA diameter was measured via cardiac multislice computed tomography (MSCT). The outcome, early PR, was assessed via echocardiography within 45 days post-operatively. Multivariable logistic regression was performed and receiver operating characteristic (ROC) curve analyses were used to identify optimal cut-off values.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eA total of 101 subjects were analysed. There was a significant association between the maximal and minimal diameters of the PVA z scores (p\u0026thinsp;=\u0026thinsp;0,001 and p\u0026thinsp;\u0026lt;\u0026thinsp;0,001, respectively) with significant PR in the univariate analysis. Multivariate analysis revealed that only the minimal diameter of the PVA z-score remained significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0,001). ROC analysis revealed that the minimal diameter of the PVA z score (area under the curve [AUC] 0,701; cut-off \u0026minus;\u0026thinsp;2,5) demonstrated moderate discriminatory ability in predicting early PR, with high specificity (90,6%) but limited sensitivity (42%).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eThe z score of the PVA minimal diameter, measured by preoperative MSCT, was consistently associated with early significant PR after ToF repair and may assist early risk stratification, although its predictive value should be interpreted alongside other clinical and intraoperative factors.\u003c/p\u003e","manuscriptTitle":"Preoperative Pulmonary Valve Annulus Diameter Z Score as a Predictor of Pulmonary Regurgitation after Tetralogy of Fallot Repair: A Retrospective Cohort Study","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-18 08:33:15","doi":"10.21203/rs.3.rs-8793939/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-03T11:34:40+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-26T15:36:46+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-26T11:11:44+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-22T06:58:15+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-21T22:06:08+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"14559274980093748415162968306523935064","date":"2026-03-19T16:35:24+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-18T04:00:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"152448818673878025008184679093513680362","date":"2026-03-18T02:34:14+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"247867091296172018066944331890609199164","date":"2026-03-16T23:34:39+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"337398010906863214592259681939619422885","date":"2026-03-16T11:56:36+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-16T05:08:03+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"30212468588697644421236746548995434037","date":"2026-03-15T08:58:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"68461073758538396671210740911602877361","date":"2026-03-13T09:16:04+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"258691784424978876331921054723134169194","date":"2026-03-13T08:44:11+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-13T08:18:15+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-02-16T11:17:00+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-02-16T11:13:08+00:00","index":"","fulltext":""},{"type":"submitted","content":"Journal of Cardiothoracic Surgery","date":"2026-02-05T07:32:31+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"journal-of-cardiothoracic-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"jcts","sideBox":"Learn more about [Journal of Cardiothoracic Surgery](http://cardiothoracicsurgery.biomedcentral.com)","snPcode":"13019","submissionUrl":"https://submission.nature.com/new-submission/13019/3","title":"Journal of Cardiothoracic Surgery","twitterHandle":"@BioMedCentral","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"BMC/SO AJ","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"a7b4b5ab-3955-459e-8499-20c1e98f90d3","owner":[],"postedDate":"March 18th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-24T06:39:01+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-18 08:33:15","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8793939","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8793939","identity":"rs-8793939","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}