Obesity complicates assessment after repair of tetralogy of Fallot (rTOF) because it can influence symptoms, exercise performance, ventricular remodeling, and the normalization of ventricular measurements. This narrative review examines the direct rTOF evidence, almost all observational, and its implications for pulmonary valve replacement (PVR) decision-making. Obesity is present in approximately 15–20% of patients (12–26% across the cohorts reviewed). In studies using absolute, height-indexed, or ideal-BSA-indexed volumes, obesity was associated with larger biventricular volumes and lower ventricular ejection fractions, and the RV volume association persisted after adjustment for PR in one study. These findings have implications for the interpretation of cardiac findings in patients with moderate-to-severe PR after rTOF. Decisions are best made by integrating all findings, with extra attention to patients with obesity. We propose an integrated assessment of symptoms, rhythms, exercise findings, and ventricular measurements.