The rastelli procedure for transposition of the great arteries: resection of the infundibular septum diminishes recurrent left ventricular outflow tract obstruction risk.
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.
Alsoufi
Bahaaldin
B
King Faisal Heart Institute, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia. balsoufi@hotmail.com
Awan
Abid
A
Al-Omrani
Ahmad
A
Al-Ahmadi
Mamdouh
M
Canver
Charles C
CC
Bulbul
Ziad
Z
Kalloghlian
Avedis
A
Al-Halees
Zohair
Z
D000015:Abnormalities, Multiple / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery; D000704:Analysis of Variance; D006348:Cardiac Surgical Procedures / Q000009:adverse effects / Q000379:methods*; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D005260:Female; D005500:Follow-Up Studies; D006345:Heart Septal Defects, Ventricular / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D006801:Humans; D007223:Infant; D007231:Infant, Newborn; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D016016:Proportional Hazards Models; D011666:Pulmonary Valve Stenosis / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D018570:Risk Assessment; D012680:Sensitivity and Specificity; D016019:Survival Analysis; D013997:Time Factors; D014188:Transposition of Great Vessels / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D016896:Treatment Outcome; D014463:Ultrasonography; D014694:Ventricular Outflow Obstruction / Q000517:prevention & control*