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Surgical debates have shifted away from 2-stage versus single-stage repairs to debates of how surgery to limit pulmonary insufficiency (PI) may have significant long-term impact as the child grows. There are many adult survivors of TOF repair in infancy who now present with a unique set of problems related to PI and right ventricular dysfunction. These adults provide new insights into congenital heart disease (CHD) and how management strategies early in life may have significant implications much later in life. 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