IntroductionTetralogy of Fallot (ToF) is the most prevalent cyanotic congenital heart defect, requiring timely surgical intervention to improve survival. Two primary techniques for right ventricular outflow tract (RVOT) reconstruction are transannular patch (TAP) repair and valve-sparing (VS) surgery as a less invasive alternative. While TAP resolves pulmonary stenosis, it often results in long-term pulmonary regurgitation (PR).Aim and ObjectivesThis meta-analysis investigates the pulmonary valve annulus (PVA) z-score as a predictor for choosing VS techniques to minimize complications, mean difference and cut-off analysis.MethodsA systematic review and meta-analysis were conducted across 32 studies (N=5,931) assessing preoperative PVA z-scores in patients undergoing TAP or VS RVOT reconstruction. Data extraction followed PRISMA guidelines, with statistical analyses using a random-effects model by Review Manager 5.4.1 and receiver operating characteristic (ROC) curve evaluation.ResultsThe meta-analysis showed significantly higher preoperative PVA z-scores in the VS group (MD: 0.99, 95% CI: 0.73–1.25, p < 0.00001). The pooled grand mean PVA z-scores were-1.48 for VS and-2.93 for TAP. ROC analysis identified a z-score threshold of ≥-2.59 (sensitivity: 81.3%, specificity: 75%) as optimal for VS surgery.ConclusionThis study establishes the PVA z-score as a robust predictor for VS approaches in ToF repair, with a proposed threshold of ≥-2.59 for optimal outcomes. Adoption of VS techniques guided by standardized z-score criteria may reduce PR- associated complications and enhance long-term survival and quality of life.