Evolution of Surgical Management in Tetralogy of Fallot: A Historical and Contemporary Review

Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease presenting beyond the neonatal period. Since its first comprehensive description by Étienne-Louis Fallot in 1888, the management of TOF has evolved remarkably - from a universally fatal condition to one with high survival and long-term quality of life. The introduction of the Blalock-Taussig shunt in 1944 provided the first effective surgical palliation by increasing pulmonary blood flow. In the 1950s, the development of cardiopulmonary bypass enabled complete intracardiac repair, which soon became the definitive treatment. Subsequent decades saw refinements in surgical technique, including the adoption of the transatrial-transpulmonary approach and pulmonary valve-sparing strategies, aimed at preserving right ventricular (RV) function. Early primary repair, now typically performed in infancy, has become the standard of care in most centers. Despite these advances, late complications such as pulmonary regurgitation, RV dilation, arrhythmias, and reinterventions remain common, necessitating lifelong follow-up. Contemporary management includes the use of multimodality imaging, transcatheter pulmonary valve replacement (TPVR), and tailored surgical planning. Emerging technologies such as artificial intelligence and computational modeling hold promise for further improving individualized care. This review outlines the historical milestones, current best practices, and future directions in the surgical treatment of TOF, highlighting its transformation from a fatal diagnosis to a survivable chronic condition requiring multidisciplinary, lifelong care.