One of the most challenging tasks in the care of adults with congenital heart disease is the risk stratification of patients with repaired tetralogy of Fallot (TOF).1 The risk of ventricular tachycardia has been relatively well defined with a number of studies providing a number of clinical variables with relatively strong negative predictive accuracy but only fair positive predictive accuracy. On the other hand, proper timing for reoperation for pulmonary valve replacement is largely based on symptoms and information acquired from imaging studies, as well as objective assessment of exercise capacity.

Natriuretic peptides are neurohormones, which are released under conditions of volume and pressure overload. Pulmonary regurgitation with progressive right ventricular dilation and residual stenosis of the right ventricular outflow tract are the main causes of the elevation of B-type natriuretic peptide (BNP) in patients with TOF. Additionally, LV systolic dysfunction and aortic regurgitation are frequent2 and may contribute to the neurohormonal activation in these patients. In contrast to patients with acquired heart …