Effects of impaired lung function and pulmonary regurgitation on maximal exercise capacity in patients with repaired tetralogy of Fallot

Right Ventricular Mass is Associated with Exercise Capacity in Adults with Repaired Tetralogy of Fallot

The relationship between exercise capacity and right ventricular (RV) structure and function in adult repaired tetralogy of Fallot (TOF) is poorly understood. We therefore aimed to examine the relationships between cardiac MRI and cardiopulmonary exercise test variables in adult repaired TOF patients. In particular, we sought to determine the role of RV mass in determining exercise capacity. Eighty-two adult repaired TOF patients (age at evaluation 26 ± 10 years; mean age at repair 2.5 ± 2.8 years; 23.3 ± 7.9 years since repair; 53 males) (including nine patients with tetralogy-type pulmonary atresia with ventricular septal defect) were prospectively recruited to undergo cardiac MRI and cardiopulmonary exercise testing. As expected, these repaired TOF patients had RV dilatation (indexed RV end-diastolic volume: 153 ± 43.9 mL/m(2)), moderate-severe pulmonary regurgitation (pulmonary regurgitant fraction: 33 ± 14 %) and preserved left (LV ejection fraction: 59 ± 8 %) and RV systolic function (RV ejection fraction: 51 ± 7 %). Exercise capacity was near-normal (peak work: 88 ± 17 % predicted; peak oxygen consumption: 84 ± 17 % predicted). Peak work exhibited a significant positive correlation with RV mass in univariate analysis (r = 0.45, p < 0.001) and (independent of other cardiac MRI variables) in multivariate analyses. For each 10 g higher RV mass, peak work was 8 W higher. Peak work exhibits a significant positive correlation with RV mass, independent of other cardiac MRI variables. RV mass measured on cardiac MRI may provide a novel marker of clinical progress in adult patients with repaired TOF.

Heart rate variability and exercise capacity of patients with repaired tetralogy of Fallot

Heart rate variability (HRV) has been used as a reliable method to detect cardiac autonomic nervous system activity. Peak oxygen uptake (VO(2) peak) has been a predictor of death for adults with repaired tetralogy of Fallot (TOF). This study investigated the correlation between HRV and exercise capacity in 30 patients with TOF after surgery for total correction. The median age of the patients was 14 years (range, 9-25 years), and the median follow-up period was 11.6 months (range, 5.3-20.2 months). Low- and high-frequency-domain HRV significantly correlated with VO(2) peak (r = 0.56, P = 0.001 and r = 0.44, P = 0.02, respectively). After the 1-year follow-up evaluation, VO(2) peak and HRV analysis did not differ from those at entry to the study. However, low- and high-frequency-domain HRV still correlated significantly with VO(2) peak (r = 0.43, P = 0.03 and r = 0.52, P = 0.007, respectively). Left ventricular early diastolic myocardial velocity was most closely correlated with the VO(2) peak (r = 0.51, P = 0.005). Impaired cardiovascular autonomic control and left ventricular diastolic dysfunction may be responsible for exercise intolerance in patients with repaired TOF. Long-term follow-up evaluation with exercise testing and 24-h Holter monitoring are warranted.

Effects of left ventricular function on the exercise capacity in patients with repaired tetralogy of Fallot

BACKGROUND

Tissue Doppler imaging has been recently used to evaluate ventricular function. Peak oxygen uptake (V•O2peak) has been demonstrated as a predictor for death in adults with repaired tetralogy of Fallot (TOF). The aim of this study was to determine which Doppler parameters correlated with V•O2peak in patients with repaired TOF.

METHOD AND RESULTS

Doppler echocardiography, tissue Doppler imaging, and exercise test were performed in 30 patients with TOF after surgical repair. In 30 patients with repaired TOF (median age 14 years, range 9-25 years), 11 patients (37%) were female. Seven patients (median age 12 years) had normal left ventricular diastolic function, whereas the rest of the patients were classified as diastolic dysfunction grade II (median age 15 years; n=15) and III and IV (median age 18 years; n=8). The oxygen uptake at anaerobic threshold (V•O2AT) and peak exercise in patients with left ventricular diastolic dysfunction was significantly lower than that in those with normal diastolic function. Also, V•O2AT and V•O2 peak in patients with diastolic dysfunction grade III and IV were significantly lower than that in those with diastolic dysfunction grade II. Left ventricular early diastolic myocardial velocity was most closely correlated to V•O2peak (r=0.51; P=0.005). Peak early ventricular filling velocity to early diastolic myocardial velocity ratio was significantly correlated with V•O2peak (r=-0.50; P=0.006).

CONCLUSION

Left ventricular diastolic dysfunction is correlated with V•O2peak. Left ventricular diastolic function should be a routine echocardiographic assessment in patients with repaired TOF.

Electrocardiographic predictors of right ventricular volume measured by magnetic resonance imaging late after total repair of tetralogy of Fallot

BACKGROUND

Right ventricular dysfunction occurs in many patients with significant pulmonary valve regurgitation late after initial total repair of tetralogy of Fallot. Methods to predict which of these patients are at increased risk of late morbidity and mortality are not yet known.

HYPOTHESIS

This study evaluated electrocardiographic (ECG) predictors of severe right ventricular dilatation determined by magnetic resonance imaging (MRI) volumes in patients with tetralogy of Fallot late after initial corrective repair.

METHODS

We retrospectively reviewed the ECGs and MRI right ventricular volume measurements of 20 patients (age 4.4 to 19.3 years, mean 10.0 years) with significant pulmonary valve regurgitation late after repair of tetralogy of Fallot. All patients had enlarged, hypokinetic right ventricles by echocardiography. The patients were grouped based on an indexed right ventricular end-diastolic volume (RVEDV/BSA) of < 102 ml/m2 (Group 1) or > or = 102 ml/m2 (Group 2). We determined the sensitivity, specificity, positive and negative predictive values of QRS duration, and mean frontal plane QRS axis for predicting right ventricular volumes.

RESULTS

A maximal QRS duration of > or = 150 ms or a northwest quadrant frontal plane QRS axis had 85% sensitivity, 86% specificity, 92% positive predictive value, and 75% negative predictive value for predicting an RVEDV/BSA of > or = 102 ml/m2. The mean QRS duration was significantly longer in Group 2 than in Group 1 patients (156 ms vs. 125 ms, p = 0.005).

CONCLUSIONS

In patients late after repair of tetralogy of Fallot with significant pulmonary valve regurgitation a maximal manually measured QRS duration of > or = 150 ms and/or a frontal plane QRS northwest quadrant axis can predict patients with marked right ventricular enlargement. The presence of either of these findings on the ECG signifies patients who require further evaluation and consideration for pulmonary valve replacement.

Cardiac magnetic resonance imaging correlates of exercise capacity in patients with surgically repaired tetralogy of Fallot

Objective exercise testing in patients with repaired tetralogy of Fallot frequently identifies gross deficiencies in exercise capacity. These findings are typically attributed to right ventricular dysfunction, pulmonary valve regurgitation, and pulmonary artery stenosis and are used to justify referrals for surgical or transcatheter interventions. However, the relation between right-sided cardiac abnormalities and exercise capacity in this patient group is poorly understood. Cardiac magnetic resonance imaging correlates of exercise capacity in 37 patients with repaired TOF were retrospectively examined. In conclusion, on multivariate analysis, right ventricular ejection fraction was the only cardiac magnetic resonance imaging predictor of percentage of predicted peak oxygen consumption, oxygen consumption at ventilatory anaerobic threshold, and oxygen pulse.

The BNP concentrations and exercise capacity assessment with cardiopulmonary stress test in patients after surgical repair of Fallot's tetralogy

Adult patients after surgical repair of Fallot's tetralogy usually present with satisfactory exercise capacity years after the original procedure, though they never tolerate as high levels of exercise as their healthy counterparts. The aim of the study was to assess exercise capacity with cardiopulmonary stress test and BNP levels in adult survivors of surgical repair of Fallot's tetralogy. We studied 60 patients with no or only mild symptoms (including 29 males), at the mean age of 27.6+/-8.2 years at the time of follow-up screening, operated on at the age of 7.5+/-5.3 years. In 34 patients moderate to severe pulmonary regurgitation (PR+) was observed. Control group consisted of 28 healthy volunteers (13 males), aged 28.7+/-5.1 years. Peak oxygen uptake (VO2) in studied group was found to be significantly lower than in control group (24.7+/-5.5 vs. 36.6+/-7.6 ml/kg/min, p=0.00001), VE/VCO2 slope, the marker of respiratory effort, was higher in surgical treatment group as compared to the control group (36.5+/-6.3 vs. 29.7+/-4.7, p=0.004). In patients with PR+, peak VO2% was higher than in PR- individuals (69.6+/-11.8% vs. 58.5+/-12.1%, p=0.0005). The BNP concentration in the studied group (34.8+/-27.1 pg/ml) was higher than in healthy subjects (11.5+/-6.5 pg/ml, p=0.00001). Levels of BNP correlated inversely with peak VO2 (r=-0.286, p=0.03), FVC (r=-0.265 p=0.04) and positively with VE/VCO2 (r=0.361, p=0.005). Additionally the levels of BNP correlated positively with the age of patients at the time of surgical repair (r=0.250, p=0.04). We concluded that exercise capacity in adults after repair of Fallot's tetralogy, especially those PR+, was lower than in healthy volunteers. Concentrations of BNP in surgical treatment survivors were higher and correlated well with cardiopulmonary stress study parameters.

Timing and type of surgery for severe pulmonary regurgitation after repair of tetralogy of Fallot

Repaired tetralogy of Fallot (rTOF) has an excellent long-term prognosis; however, survival is somewhat less than normal. Of all the residual lesions and sequellae after rTOF, pulmonary regurgitation (PR) is the most important, correlating with right ventricular (RV) size, exercise intolerance and serious ventricular arrhythmias. Pulmonary valve replacement (PVR) has beneficial effects on RV size and function, provided it is performed early, before irreversible RV dysfunction ensues. Moreover, PVR is associated with an improvement in patients' symptoms and exercise tolerance and combined with arrhythmia surgery (cryoablation) it leads to a dramatic decrease in the incidence of fatal ventricular arrhythmias. Associated lesions, especially branch pulmonary artery stenosis, which aggravates PR, and tricuspid regurgitation, which further impacts on RV size and function, need addressing. Large right ventricular outflow (RVOT) akinetic and aneurysmal regions are frequent and further compromise RV function; therefore, resection during PVR should be attempted. Despite excellent mid-term results, homografts and xenografts, usually used for RVOT reconstruction, suffer late dysfunction and failure, committing patients and surgeons to further operations. Therefore, the decision to operate should be based on the balance between progressive RV dilatation, exercise intolerance, symptoms, arrhythmias and the fact that further reoperations will be needed. Research on the ideal valve for RVOT reconstruction is ongoing. Prospective follow-up of patients with rTOF with exercise testing and assessment of RV size and function, preferably with magnetic resonance, will define better the natural history of the disease and will probably provide firm guidelines for PVR timing especially in asymptomatic patients.

Influence of early repair of tetralogy of fallot without an outflow patch on late arrhythmias and sudden death: a 27-year follow-up study following a uniform surgical approach

Pulmonary regurgitation and older age at the time of repair may have a large impact late after repair on subsequent mortality of patients with tetralogy of Fallot. We aimed to identify whether age at repair, and preservation of the pulmonary valve, had a favorable influence on morbidity and mortality. We also analyzed risk factors for late death subsequent to surgical repair. We identified 167 patients who, between 1965 and 1975, and at a mean age of 6 years, underwent total repair of tetralogy of Fallot by a single surgical team without use of an outflow patch. All patients were known to have survived for at least 30 days after repair, and late mortality was identified though the use of hospital records, interviews, and death certificates. The 29-year actuarial survival rate was 86%, with 24 late deaths. Of these deaths, seven occurred suddenly (4.2%). Morbidity was analyzed in 99 of the patients by means of a written questionnaire and telephone interview. It proved possible to analyze ventricular and valvar function in 50 of the patients. Survivors experienced no re-intervention, and 89% of them were in class I of the grading system of the New York Heart Association. We found evidence of 3 episodes of sustained ventricular tachycardia (3.0%), and two episodes of atrial tachycardia (2.0%). Of the 50 patients in whom serial examinations were available, 18 had pulmonary regurgitation of moderate degree or greater, and none had more than moderate tricuspid regurgitation, with a mean QRS duration of 148 ms and an ejection fraction for the left ventricle of 50%. Older age at repair (p = 0.03), and longer periods of cardiac arrest during repair (p = 0.02), were associated with late mortality. Although the mortality was similar to that observed in previous reports, our operative method might have a better effect in terms of late morbidity.

Exercise MR imaging in the assessment of pulmonary regurgitation and biventricular function in patients after tetralogy of fallot repair

PURPOSE

To assess the responses of pulmonary regurgitation (PR) and biventricular function to submaximal exercise by using a magnetic resonance (MR) imaging exercise protocol with young adult patients who underwent tetralogy of Fallot repair at a young age.

MATERIALS AND METHODS

Fifteen patients with corrected tetralogy of Fallot (mean age, 17.5 years +/- 2.5 [SD]) underwent MR imaging at rest and during exercise for the evaluation of PR and biventricular function. Results were compared with findings from 16 control subjects (mean age, 17.5 years +/- 2.3). Mean age at tetralogy of Fallot repair was 2.1 years +/- 1.6, and mean follow-up time after repair was 15.4 years +/- 2.6. Exercise level at MR imaging was calculated individually and corresponded to 60% of peak oxygen uptake. The parameters of cardiac function obtained at rest and during exercise were compared by using a paired t test. An unpaired t test was used to compare parameters of cardiac function between patients and control subjects.

RESULTS

PR decreased during exercise (from 27 mL/m(2) +/- 17 to 23 mL/m(2) +/- 15; P =.012). At rest, right ventricular (RV) ejection fraction was normal (>47%) in 80% of patients. RV response to exercise in the patient group was abnormal compared with response in the control group, as demonstrated by an increase in RV end-diastolic volume index (132 mL/m(2) +/- 36 to 137 mL/m(2) +/- 38; P =.041) and no significant change in end-systolic volume index or ejection fraction. In only one patient, RV ejection fraction increased by more than 5%. Left ventricular response was not different between patients and control subjects.

CONCLUSION

MR imaging is well suited to assess cardiac response to exercise, and findings revealed a decrease in PR and an abnormal RV response to exercise in patients with corrected tetralogy of Fallot.

Early age at repair prevents restrictive right ventricular (RV) physiology after surgery for tetralogy of Fallot (TOF): diastolic RV function after TOF repair in infancy

OBJECTIVES

To assess diastolic right ventricular (RV) physiology after tetralogy of Fallot repair in infancy.

BACKGROUND

Restrictive RV physiology after tetralogy of Fallot repair is related to type of repair, pulmonary regurgitation, and late arrhythmias.

METHODS

Forty-seven patients were investigated, 27 and 20 patients in Lund and London, respectively. Median age at repair was 0.78 years (0.08-0.99) and median follow-up was 3.0 years (0.08-10.4). Restrictive RV physiology was assessed by Doppler echocardiography.

RESULTS

Thirteen patients (28%) had restrictive RV physiology at follow-up, three of 19 patients (16%) with transatrial repair and 10 of 28 patients (32%) with transventricular repair, respectively (p=0.1). Ten percent of the patients repaired before 6 months of age were restrictive at follow-up, increasing to 38% with repair after 9 months. Transannular patch (TAP) repair was performed in 55% of the patients, including eight of 10 patients (80%) with repair before 6 months of age. Thirty-one percent of the patients with TAP repair were restrictive. These restrictive patients had more severe preoperative pulmonary stenosis (p < 0.05), were older at repair (p < 0.05), and had shorter duration of pulmonary regurgitation (p < 0.001) at follow-up.

CONCLUSIONS

Restrictive RV physiology is inversely related to age at repair and independent of type of outflow tract repair. Since TAP repair is more common in early repair, and restriction seems to be less frequent, long-term follow-up to assess adverse effects of pulmonary regurgitation is mandatory.

Role of right ventricular and pulmonary functional abnormalities in limiting exercise capacity in adults with congenital heart disease

This study evaluates right ventricular (RV) and pulmonary function during exercise in adults with congenital heart disease (CHD). Thirty-one patients with CHD involving the right side of the heart underwent symptom-limited bicycle exercise testing with simultaneous expired gas analysis and measurement of RV ejection fraction (EF). Twenty-one age-matched normal controls underwent the identical exercise protocol. Maximal oxygen consumption was lower in the CHD than in normal controls (19.5 +/- 6.4 vs 30.5 +/- 0.8 ml/kg/min, p = 0.0001 patients vs controls). Both heart rate (156 +/- 25 vs 171 +/- 13 beats/min, p = 0.01) and oxygen pulse (9.3 +/- 3.7 vs 12.3 +/- 3.7 ml/beat, p = 0.01), an indirect measure of stroke volume, were found to be lower in the CHD group at peak exercise. Pulmonary dysfunction was evidenced in the CHD group by decreased forced expiratory volume, forced vital capacity and maximum voluntary ventilation, and by a higher ventilation/expired carbon dioxide ratio at peak exercise (37.2 +/- 6.9 vs 33.0 +/- 5.4, p = 0.02), suggesting an increase in dead space ventilation. Maximal oxygen consumption was lower in patients whose RVEF decreased with exercise (17.6 +/- 5.4 vs 22.8 +/- 6.4 ml/kg/min, p = 0.03 "decrease RVEF" group vs "increase RVEF" group). Maximal oxygen consumption correlated with the change in RVEF only in the group whose RVEF decreased with exercise (r = 0.5, p = 0.03). In the group that had increased RVEF with exercise, maximal oxygen consumption correlated with forced expiratory volume (r = 0.7, p = 0.02). Thus, adults with CHD have a reduced functional capacity compared with normal controls. This phenomenon appears to be associated with both RV and pulmonary abnormalities.

Relationship between type of outflow tract repair and postoperative right ventricular diastolic physiology in tetralogy of Fallot. Implications for long-term outcome

BACKGROUND

Restrictive right ventricular (RV) physiology can be present early and late after tetralogy of Fallot repair. It is associated with a complicated early postoperative course but is favorable late after repair because it is associated with less pulmonary regurgitation, better exercise tolerance, and less QRS prolongation and symptomatic ventricular arrhythmias. It is not known, however, whether in the current surgical era, this physiology is present in tetralogy of Fallot patients at mid-term follow-up and whether it is related to the type of RV outflow tract repair. Finally, the impact of this physiology on the early evolution of QRS prolongation has not been examined previously. In this study we attempted to address these issues in a cohort of recently operated patients.

METHODS AND RESULTS

Ninety-five patients were studied 4.3 years after repair by Doppler echocardiography, serial electrocardiograms, and chest radiographs. Restrictive RV physiology defined by the presence of antegrade pulmonary artery flow in late diastole was present in 38% of the patients. It was more common in patients with transannular patch (TAP) repair compared with non-TAP repair (50% versus 21%, P < .05). QRS duration at follow-up was 121.2 +/- 17.6 and 132.6 +/- 11.8 ms in restrictive and nonrestrictive patients with TAP repair, respectively (P < .02).

CONCLUSIONS

Restrictive RV physiology has been identified at mid-term follow-up in a contemporary surgical series. It is associated with less QRS prolongation, regardless of the technique used for outflow tract repair, and may be associated with fewer long-term complications. Nonrestrictive physiology is associated with the most marked QRS prolongation. This subgroup is most at risk from the late deleterious consequences of chronic pulmonary regurgitation.

Left ventricular dysfunction on exercise long-term after total repair of tetralogy of Fallot

BACKGROUND

Excellent results regarding mortality are well recognized in the long-term period after intracardiac repair of tetralogy of Fallot. However, it is still unclear how postoperative sequelae affect cardiac performance during exercise.

METHODS AND RESULTS

Twenty-nine patients with tetralogy of Fallot were studied 16 +/- 2 years after intracardiac repair by use of radionuclide first-pass ventriculography with an ultra-high-sensitive gamma camera at rest and at peak exercise on a semi-upright bicycle ergometer. The results were compared with those from 10 age- and sex-matched control subjects. Left and right ventricular ejection fraction and absolute ventricular volume were measured at rest and peak exercise. Regional right ventricular wall motion and diastolic function of the left ventricle were also assessed. Cardiac output of tetralogy was normally preserved both at rest and during exercise. Nevertheless, the incremental response of left ventricular ejection fraction during exercise was depressed in the patients. Left ventricular ejection fraction during exercise was inversely correlated with the right ventricular end-diastolic volume and the severity of pulmonary regurgitation. Regional wall motion at the right ventricular outflow tract was not decreased in the patients. Left ventricular diastolic function was not impaired in the patients compared with control subjects.

CONCLUSIONS

Latent left ventricular dysfunction during exercise is related to an enlarged right ventricle due to pulmonary regurgitation after intracardiac repair of tetralogy. Careful follow-up is required in patients having significant pulmonary regurgitation.

Ventilatory responses to exercise in adults after repair of tetralogy of Fallot

BACKGROUND

Adult patients with total correction of tetralogy of Fallot may have poor exercise capacity associated with impaired right heart function and in particular pulmonary regurgitation. The ventilatory responses to exercise were studied in a group of such patients to assess relations between ventilation, exercise capacity, and right ventricular function.

METHODS

30 patients (7 female) (aged 27.8 (6.0) years) and 30 (7 female) controls of a similar age range were studied prospectively. All underwent exercise testing with metabolic gas exchange to determine peak oxygen consumption (peak VO2), and (as indices of the ventilatory response) the slope of the relation between both respiratory rate (RR) and ventilation (VE) against carbon dioxide production (VCO2). Patients were studied with pulsed wave Doppler echocardiography to determine pulmonary arterial systolic and diastolic flow characteristics. Patients were defined as having restrictive right ventricular function where diastolic pulmonary forward flow was seen coincident with atrial systole.

RESULTS

In the group with tetralogy of Fallot mean (SD) peak VO2 was 35.3 (7.5) ml/kg/min (93.6 (15.3) % of expected for age, weight, height and sex). The RR/VCO2 slope was steeper in the Fallot group (6.8 (2.6) v 9.6 (4.7), P < 0.02). Those with restrictive right ventricles achieved a higher peak VO2 than those without (82.5 (10.1) % v 100.9 (13.8), P < 0.001). In the Fallot group alone, there was an inverse relation between ventilatory response and peak VO2 (RR/VCO2 v peak VO2; r = -0.63, P = 0.003: VE/VCO2 v peak VO2; r = -0.62, P < 0.001).

CONCLUSIONS

Many of these patients with repaired tetralogy of Fallot had near normal exercise capacity, but as exercise capacity decreased, the ventilatory response to exercise increased. This was not due to alterations in pulmonary function tests or to the effects of cardiac size causing decreased lung volume. It may be that the increased ventilatory rate at a given level of carbon dioxide production acts as a respiratory pump aiding right ventricular function.

Variability of digitized left ventricular M-mode echocardiography: a study in healthy subjects and patients with repaired tetralogy of Fallot

To assess possible factors affecting the variability of digitized left ventricular M-mode echocardiograms, the influence of respiration and the variability due to different beats and observers were analysed in 11 healthy subjects and 11 patients with repaired tetralogy of Fallot. Left ventricular end-diastolic dimension (LVEDD) decreased from end-expiration to end-inspiration in the healthy subjects, but not in the patients. The maximal rate of dimension change decreased in both healthy subjects and patients from end-expiration to end-inspiration. The beat-to-beat variability assessed by the coefficient of variation (CV,%) between measurements of one cardiac cycle was twice the CV for three cycles, whereas the CV for three and five cardiac cycles was not different. The CV for intraobserver variability was less than 5.0% for dimensions and less than 13.0% for the rates of dimension change, whereas the interobserver variability had CV of 17.1% for rates of dimension changes. The influence of respiration and different observers on the variability of LV end-systolic dimension and shortening fraction was larger in the patients than in the healthy subjects. Thus, to obtain optimal technique for analysis of digitized LV M-mode echocardiograms in serial patient studies, the number of observers should be kept at a minimum and at least 3 beats at end-expiration should be used.

Hemodynamic status in repaired tetralogy of Fallot assessed by Doppler echocardiography and cardiac catheterization. Comparisons with healthy subjects and elucidation of factors associated with cardiorespiratory function

Thirty-four patients were studied after corrective surgery for tetralogy of Fallot (mean follow-up 10 years) and compared with healthy matched controls. All underwent Doppler echocardiography, spirometry and treadmill exercise test. Post-operative cardiac catheterization had been performed on 26 (76%) of the patients and showed poor hemodynamic results in four (15%). Significant correlations of pressure gradients obtained from catheterization and estimated by Doppler echocardiography were right ventricular to right atrial (r = 0.77), pulmonary outflow (r = 0.75), pure valvular pulmonary outflow (r = 0.94) and diastolic pulmonary pressure gradients (r = 0.53). Pulmonary outflow gradients and right ventricular to right atrial pressure gradients estimated from tricuspid regurgitation jets were significantly increased in the patients. Diastolic pulmonary artery pressure, vital capacity and ventilatory anaerobic threshold were independent factors of maximal oxygen consumption. It is suggested that Doppler-derived diastolic pulmonary artery pressure, lung function studies and exercise testing with assessment of the ventilatory anaerobic threshold should be included in follow-up after repair of Fallot's tetralogy.