Patients with repaired tetralogy of Fallot (TOF) are increasingly seen in cardiology practice given the success of surgical repair procedures in infancy and childhood. However, many of these patients require reoperation in young adulthood for pulmonic valve regurgitation and they remain at increased risk of ventricular tachycardia and sudden death. In a study of 90 consecutive adults with repaired TOF, compared to 15 age and sex matched control subjects, an elevated serum brain natriuretic peptide (BNP) level was a strong predictor of death (HR 1.16 per 10 pmol/L, 95% CI 1.05 to 1.29; p<0.01). (see page 447). In TOF patients, a BNP≥15 pmol/L (=52 pg/mL) was associated with an absolute mortality of 19% at 5 years compared to 3% in those with a lower BNP level. Dr Babu-Narayan and colleagues conclude that neurohormonal activation in asymptomatic TOF patients should be incorporated into the routine longitudinal assessment of these patients Figure 1.

In an editorial, Dr Giannakoulas and colleagues (see page 416) comment that there are several …