Highlights
•Deciding the optimal timing of PVR is challenging in TOF, based on the RV size.
•A higher energy loss ratio was the most important factor in symptomatic TOF.
•RVEF was inversely related to average and diastolic energy loss in adult TOF.
•Diastolic energy loss was a powerful predictor of symptom in TOF with PS and PR.

Yumi Shiina MD, PhD, Michinobu Nagao MD, PhD, Keiichi Itatani MD, PhD, Eriko Shimada MD, Kei Inai MD, PhD, "4D flow MRI-derived energy loss and RV workload in adults with tetralogy of Fallot", Journal of Cardiology, Published Online (2023) https://doi.org/10.1016/j.jjcc.2023.10.003.