Original article
Pediatric cardiac
The Rastelli Procedure for Transposition of the Great Arteries: Resection of the Infundibular Septum Diminishes Recurrent Left Ventricular Outflow Tract Obstruction Risk

Presented at the Forty-fifth Annual Meeting of The Society of Thoracic Surgeons, San Francisco, CA, Jan 26–28, 2009.
https://doi.org/10.1016/j.athoracsur.2009.03.099Get rights and content

Background

The Rastelli procedure is the standard surgical treatment of d-transposition of great arteries (d-TGA), ventricular septal defect (VSD), and pulmonary stenosis. Late morbidity is significant due to recurrent left ventricular outflow obstruction (LVOTO), early conduit obstruction, and arrhythmias, with troublesome late mortality. To avoid recurrent LVOTO, we routinely enlarge the VSD and resect the infundibular septum before LV baffling to the aorta. We examined the efficacy of this approach in mitigating recurrent LVOTO risk.

Methods

Late echocardiographic and time-related clinical results of patients undergoing the Rastelli procedure were examined. Demographics and operative variables affecting outcomes were analyzed.

Results

The Rastelli cohort comprised 36 patients with d-TGA, VSD, and pulmonary stenosis. Median age at operation was 2.4 years (range, 0.3 to 8.3 years). Pulmonary stenosis was present in 31 and atresia in 5. Twenty-two patients had undergone a previous aortopulmonary shunt, and 6 had an atrial septectomy. No operative or late deaths occurred. Time-related freedom from permanent pacemaker implantation, recurrent LVOTO on echocardiogram, and conduit replacement at 10 years was 82%, 100%, and 49%, respectively. Systolic function was normal in all but 3 patients and 92% were in New York Heart Association functional class I and II. None of the patients had late arrhythmias or required heart transplantation.

Conclusions

Early and midterm survival after the Rastelli procedure is satisfactory. Aggressive resection of the infundibular septum to enlarge the VSD has mitigated the risk of LVOTO recurrence. Late conduit obstruction remains an important source of morbidity and frequently requires reintervention.

Section snippets

Patients and Methods

Approval of this study was obtained from the Research Ethics Board at our institution, and requirement for individual consent was waived for this observational study.

Results

The study included 36 consecutive patients (21 boys, 15 girls) with d-TGA, VSD and PS. Median age was 2.4 years (range, 111 days to 8.3 years). Pulmonary stenosis was present in 31 patients and pulmonary atresia in 5. Twenty-two patients had undergone a previous aortopulmonary shunt, and 6 had a previous atrial septectomy. Additional cardiac anomalies included 3 with multiple VSDs, 2 with dextrocardia, and 1 patient each with total anomalous pulmonary venous connection, coarctation of the

Comment

The Rastelli procedure was first introduced in 1969 and soon became the conventional surgical management for patients with d-TGA, VSD, and PS [1, 2]. Nonetheless, published clinical data have shown the long-term results of the Rastelli procedure are far from optimal, with diminished long-term survival, depressed ventricular function, and increased reintervention on the RVOT or LVOT [3, 4, 5, 6].

References (19)

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