With the increasing number of late survivors of repair of tetralogy of Fallot, surgical management of patients with right ventricular (RV) dysfunction and limited exercise capacity has become a more frequent problem. The wide variability in clinical status, extent of RV dilatation, and dysfunction at the time of presentation for surgical intervention has resulted in disparate surgical results after pulmonary valve insertion. With increasing use of magnetic resonance imaging, quantitative measures of RV volumes, function, and pulmonary regurgitant fraction have enabled a more systematic analysis of results. While there is a group of patients that responds favorably to pulmonary valve insertion, there is also a large subgroup that does not; this requires further analysis of the mechanisms responsible. We have developed a surgical approach to this latter group of patients, which incorporates the concepts of ventricular remodeling or restoration developed for the left ventricle following myocardial infarction. Preliminary results indicate that this procedure is equally safe to pulmonary valve insertion alone, and may result in improved RV function.