Objective To review the clinical data of patients with tetralogy of Fallot (TOF) treated by different surgical routes in recent years and to explore the indications for the trans-right atrium-pulmonary artery route. Methods: From January 2007 to July 2011, a total of 227 consecutive patients underwent radical surgery for TOF, with the exception of patients with TOF combined with pulmonary atresia, atrial septal defect and other malformations, and those who underwent bypass surgery in the first stage. The main points of the improved surgical technique included unblocking the right ventricular outflow tract through the right atrial tricuspid orifice and repairing the ventricular septal defect by pulmonary artery leaflet junctional dissection, except for cases with sub-stem ventricular septal defect. If the pulmonary trunk and annulus are dysplastic, the limited length of the pulmonary trunk and pulmonary annulus to the right ventricular funnel is incised, usually 0.5-1.5 cm under the annulus, and the pericardial slices widen the pulmonary artery and annulus. If the funnel is significantly dysplastic, the incision is extended to the inferior border of the funnel septum, and the incision length is usually less than 2.5 cm, and the right ventricular outflow tract is widened with a valved bovine jugular vessel piece. Postoperative management was routinely ventilator-assisted with dobutamine, epinephrine and milrinone applied to support cardiac function, and no extracorporeal membrane oxygenator (ECMO) cases were applied. Peritoneal dialysis was used for those who developed renal insufficiency. According to the surgical pathway cases were divided into 3 groups, right atrial pathway group alone (RA group, n=65,29%); right atrial and pulmonary artery pathway group (RA-PA group, n=70,31%); and right atrial-pulmonary artery-right ventricular outflow tract pathway group (RA-PA-RVOT group, n= 97,43%). The retrospective analysis parameters, in addition to the general clinical data, included pulmonary valve annulus Z value, McGoon value, right ventricular to left ventricular peak pressure ratio (pRV/LV) measured directly after extracorporeal circulatory arrest and circulatory stabilization, postoperative duration of mechanical ventilation, ICU stay, incidence of important postoperative complications, and mortality. The postoperative right ventricular outflow tract pressure difference changes. All data were processed using SPSS 16.0 software. p<0.05 was considered a statistically significant difference. Results The sex ratios were 34/31, 39/30 and 47/50; age was 38.3±27.5m, 36.7±38.9m and 43.1±41.8m, respectively; weight was 12.7±3.78kg, 14.2±8.22kg and 14.5±6.49kg, respectively; preoperative oxygen saturation was 82.7±9.14%, 82.8±8.24% and 82.8±8.24%, respectively. The preoperative hemoglobin was 156.3±34.4g/l, 160.7±32.9g/l and 161.7±31.4g/l, respectively; there was no significant difference between the above-mentioned sex, age, oxygen saturation and hemoglobin groups (p>0.05). The right ventricular outflow tract pressure difference (PG,mmHg) measured by preoperative ultrasound was 87.0±16.2, 98.3±25.6 and 94.9±26.8, respectively, and there was a significant difference between RA group and RA-PA group and RA-PA-RVOT group (p < 0.05). Pulmonary annulus Z values were -0.8 ± 1.3, -2.6 ± 1.8 and -3.7 ± 1.9, respectively, with significant differences between groups when comparing each group (p < 0.05). McGoon values were 1.8 ± 0.4, 1.7 ± 0.6 and 1.5 ± 0.4, respectively, with significantly lower values in the RA-PA-RVOT group than in the RA and RA-PA groups (p < 0.05). The pRV/LV in the three groups were 0.52±0.12, 0.56±0.13 and 0.58±0.14, respectively, with no significant difference between the groups (p>0.05). There were 4 perioperative deaths (1.7%), all of which were cases in the RA-PA-RV group. The incidence of postoperative complications including hypocapnia, acute renal insufficiency, atrioventricular block and pleural effusion was 8%, 16% and 29%, respectively (P<0.05). The duration of postoperative mechanical ventilation was 24.3±38.6h, 42.5±51.9h and 52.5±74.1h, respectively; the duration of ICU stay was 55.2±55.3h, 76.3±61.3h and 98.4±111.4h, respectively; and the number of postoperative hospital days was 8.1±3.3, 11.1±7.9 and 13.5±10.9, respectively. These three indicators The analysis showed a significant difference between the RA and RA-PA groups compared to the RA-PA-RV group (P<0.05). The postoperative follow-up rate was 81.4%, and the follow-up period ranged from 1 month to 53 months. There were no deaths and no life-threatening arrhythmias during the follow-up period. The right ventricular outflow tract pressure difference decreased to different degrees in all groups by echocardiography. All patients with tetralogy of Fallot can have their RVOT unblocked and septal defects repaired by the RA pathway (except for the inferior stem type); radical surgery via the right atrium/pulmonary artery pathway is appropriate when the Z value of the pulmonary valve annulus is greater than -3 and the McGoon value is greater than 1.5; radical surgery via the right atrium/pulmonary artery pathway can be performed in more than half of the patients; radical surgery via the right atrium/pulmonary artery pathway is likely to improve Surgical outcomes are likely to be improved.