Risk factors for SCD include: a. LV systolic or diastolic dysfunction b. Nonsustained VT c. QRS duration 180 ms d. Extensive RV scarring e. Inducible sustained VT at electrophysiological study The largest study of patients with repaired TOF and ICDs included 121 patients from 11 North American and European sites followed for a median of 3.7 years after ICD implantation. Overall, 30% of patients received at least 1 ap- propriate ICD discharge, corresponding to annual appropriate shock rates of 7.7% and 9.8% for primary and secondary prevention indications, Unlike patients with acquired HF, evidence suggests that patients with TOF who have inducible sustained polymorphic VT (hazard ratio: 12.9) fare as poorly as or worse than those with inducible sustained monomorphic VT.S4.3.5-5 Negative consequences associated with ICDs in adults with TOF must be carefully considered in selecting appropriate candidates. These include high rates of inappropriate shocks (5% to 6% per year), lead-related complications, and unfa- vorable patient-reported outcomes, including im- paired QoL, anxiety, depression, and psychosexual 8. In patients with repaired TOF and moderate or greater PR who are undergoing cardiac surgery for a separate lesion (eg, RVOT aneurysm, TR, branch PA stenosis, residual VS D, arrhythmia ablation, coronary artery revascularization, aortic root re- placement), it may be reasonable to concurrently perform pulmonary valve replacement.S4.3.5-41 9. Although correction of the hemodynamic lesion (ie, PR), may be clinically beneficial, pulmonary valve replacement alone has not consistently been demonstrated to reduce risk of subsequent VT or SCD.S4.3.5-42 Thus, in addition to pulmonary valve replacement, VT surgery and/or ICD implan- tation may be considered.S4.3.5-43 4.3.6. Right Ventricle to-Pulmonary Artery Conduit Recommendations for Right Ventricle to-PA Conduit Referenced studies that support recommendations are summarized in Online Data Supplement 44. 