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Objective: There is a high burden of reintervention after repair of tetralogy of Fallot (TOF). We compare procedural burden and late outcomes in valve-sparing repair (VSR) and transannular patch (TAP) cohorts over 30 years., Methods: Patients undergoing TOF repair (1990-2021, excluding complex TOF) were included in this study (n = 1239) with subsequent comparisons between TAP (n = 550) and VSR (n = 648) cohorts. Descriptive statistics, cumulative incidence frequencies, survival analysis, and propensity matching (n = 425) were used to analyze reintervention burden and survival., Results: Overall survival of the cohort was 96.7% at 15 years and 95.6% at 25 years, with similar survival between TAP and VSR cohorts (P = .22). The TAP cohort had increased incidence of procedural burden at 25 years (TAP 69.8% vs VSR 37.2%; P < .001), with 34.6% undergoing ≥2 reinterventions. The TAP cohort had higher incidence of surgical pulmonary valve replacement at 15 years (TAP 20.7% vs VSR 7.6%; P < .001) and placement of pulmonary artery stents (TAP 20.2% vs VSR 4.9%; P < .001). By contrast, VSR had higher incidence of right ventricular outflow tract (RVOT) reoperation at 15 years (VSR 7.3% vs TAP 3.6%; P = .047). After propensity score matching there was no survival advantage between the VSR and TAP cohorts (Era 2), whereas the need for RVOT reoperation was not different between the 2 cohorts (P = .060)., Conclusions: The procedural burden remains high following TOF repair. TAP is associated with higher procedural burden in matched and nonmatched cohorts. VSR has increased risk of reoperation for RVOT obstruction only in nonmatched comparisons. Anatomical complexity and surgical repair strategy influence procedural burden following TOF repair., Competing Interests: Conflict of Interest Statement The authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handing or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest., (Copyright © 2024 The American Association for Thoracic Surgery. Published by Elsevier Inc. All rights reserved.)