Individuals with repaired tetralogy of Fallot (TOF) comprise a substantial proportion of the current adult congenital heart disease population. Pulmonary regurgitation (PR) is one of the most prevalent postoperative sequelae, but timing of pulmonary valve replacement (PVR) in the asymptomatic TOF patient remains controversial. We sought to explore thresholds for PVR referral among adult congenital physicians. Physicians attending an international adult congenital cardiac disease conference were given a survey focusing on PVR referral patterns for the asymptomatic individual with repaired TOF. Survey questions related to an asymptomatic adult with repaired TOF, at least moderate PR, and varying degrees of right ventricular (RV) dilation and RV dysfunction. A total of 128 surveys were completed. Nine percent did not feel that PVR was indicated in the asymptomatic patient. Of those practitioners who felt that PVR was indicated, many [(69%, [74/107]) relied on RV end-diastolic volumes (RVEDV) to guide decision making. Fewer relied on RVEDV for surgical referral as RV ejection fraction (EF) decreased. RVEDV thresholds for PVR referral varied depending on the RV function: with normal RVEF, 180 cc/m(2) was the most commonly used cutoff; if RV dysfunction was significant, 150 cc/m(2) was the threshold most often cited. Physicians who utilized RV volumes to guide decision making tended to work in a tertiary care setting (P= 0.008). PVR referral patterns for an asymptomatic TOF patient with significant PR and important RV dilation are variable among adult congenital cardiologists. Uncertainty regarding thresholds for PVR referral underscores the need for further study of this important issue.