The Rastelli Procedure for Transposition of the Great Arteries: Resection of the Infundibular Septum...

DOI: 10.1016/j.athoracsur.2009.03.099 2009;88:137-143 Ann Thorac Surg

Canver, Ziad Bulbul, Avedis Kalloghlian and Zohair Al-Halees Bahaaldin Alsoufi, Abid Awan, Ahmad Al-Omrani, Mamdouh Al-Ahmadi, Charles C.

Obstruction RiskInfundibular Septum Diminishes Recurrent Left Ventricular Outflow Tract

The Rastelli Procedure for Transposition of the Great Arteries: Resection of the

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he Rastelli Procedure for Transposition of thereat Arteries: Resection of the Infundibulareptum Diminishes Recurrent Left Ventricularutflow Tract Obstruction Risk

ahaaldin Alsoufi, MD, Abid Awan, MD, Ahmad Al-Omrani, MD,amdouh Al-Ahmadi, MD, Charles C. Canver, MD, Ziad Bulbul, MD,vedis Kalloghlian, MD, and Zohair Al-Halees, MD

ing Faisal Heart Institute, King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia

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Background. The Rastelli procedure is the standardurgical treatment of d-transposition of great arteriesd-TGA), ventricular septal defect (VSD), and pulmonarytenosis. Late morbidity is significant due to recurrenteft ventricular outflow obstruction (LVOTO), early con-uit obstruction, and arrhythmias, with troublesome lateortality. To avoid recurrent LVOTO, we routinely en-

arge the VSD and resect the infundibular septum beforeV baffling to the aorta. We examined the efficacy of thispproach in mitigating recurrent LVOTO risk.Methods. Late echocardiographic and time-related clin-

cal results of patients undergoing the Rastelli procedureere examined. Demographics and operative variables

ffecting outcomes were analyzed.Results. The Rastelli cohort comprised 36 patients with

-TGA, VSD, and pulmonary stenosis. Median age atperation was 2.4 years (range, 0.3 to 8.3 years). Pulmo-
ary stenosis was present in 31 and atresia in 5. Twenty-
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2009 by The Society of Thoracic Surgeonsublished by Elsevier Inc

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wo patients had undergone a previous aortopulmonaryhunt, and 6 had an atrial septectomy. No operative orate deaths occurred. Time-related freedom from perma-ent pacemaker implantation, recurrent LVOTO on echo-ardiogram, and conduit replacement at 10 years was2%, 100%, and 49%, respectively. Systolic functionas normal in all but 3 patients and 92% were in Nework Heart Association functional class I and II. Nonef the patients had late arrhythmias or required heartransplantation.

Conclusions. Early and midterm survival after the Ras-elli procedure is satisfactory. Aggressive resection of thenfundibular septum to enlarge the VSD has mitigatedhe risk of LVOTO recurrence. Late conduit obstructionemains an important source of morbidity and frequentlyequires reintervention.

(Ann Thorac Surg 2009;88:137–43)
© 2009 by The Society of Thoracic Surgeons
ptimal surgical treatment of d-transposition of thegreat arteries (d-TGA), ventricular septal defect

VSD), and pulmonary stenosis (PS) remains controver-ial. Since its description by Gian Carlo Rastelli in 1969,he Rastelli operation has been considered the treatmentf choice for this challenging defect [1, 2]. Nonetheless,

ate outcomes after the Rastelli operation have beenssociated by prominent late mortality and morbidity3–6]. Development of left ventricular outflow tract ob-truction (LVOTO) caused by the natural tendency ofSD to close over time, as well as the inability of thertificial material used to construct the LVOT tunnel torow, can result in LV dysfunction that may have an

mportant effect in the late mortality observed after theastelli operation [4, 7].

ccepted for publication March 31, 2009.

resented at the Forty-fifth Annual Meeting of The Society of Thoracicurgeons, San Francisco, CA, Jan 26–28, 2009.

ddress correspondence to Dr Alsoufi, King Faisal Heart Institute (MBC

The policy at our institution is to perform routineggressive enlargement of the VSD at the time of theastelli operation, with anterosuperior enlargement of

he defect and routine resection of the infundibulareptum. In the current series, we describe clinical andchocardiographic outcome in patients after the Rastelliperation and examine if routine VSD enlargement pol-

cy has mitigated the risk of development of LVOTO.

atients and Methods

pproval of this study was obtained from the Researchthics Board at our institution, and requirement for

ndividual consent was waived for this observationaltudy.

nclusion Criteriarom 1992 to 2005, 36 consecutive children with d-TGA,SD, and PS received the Rastelli biventricular repair at

he King Faisal Specialist Hospital and Research Centern Riyadh, Saudi Arabia. Clinical, operative, and outcome
ata were abstracted from their medical records.
0003-4975/09/$36.00doi:10.1016/j.athoracsur.2009.03.099

Zohair Al-Halees on August 23, 2009

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138 ALSOUFI ET AL Ann Thorac SurgRASTELLI PROCEDURE FOR D-TGA 2009;88:137–43

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perative Detailsll operations are performed through a midline sternot-my. After adhesions are taken down and aortopulmo-ary shunts are exposed, conventional cardiopulmonaryypass is initiated with standard aortic and bicaval can-ulation in all patients. The left heart is vented through

he right superior pulmonary vein. Moderate hypother-ia of 28° to 32°C is obtained while myocardial protec-

ion is provided, with antegrade cardioplegia infusionhrough the aortic root given every 20 minutes.

Once cardiopulmonary bypass is started, the pulmonaryrtery branches are adequately mobilized and the exposedodified Blalock-Taussig shunt is externally clipped and

ivided to avoid traction on the pulmonary artery as thehild grows. After aortic cross-clamp application, the mainulmonary artery is transected distal to the pulmonary valvend is oversewn at the level of the pulmonary annulus.

A longitudinal right ventriculotomy is made in lineith the proposed conduit path with care to avoid any

njury to any major epicardial coronary vessel. Muscleundles are resected on both sides of the ventriculotomy

ig 1. The surgical method used in the Rastelli cohort (A) Right ventrre placed to provide exposure to the ventricular septal defect (VSD) aion of a wedge of the septal tissue anterosuperiorly using an 11 bladhe aortic valve is usually done. (C) A cylindrical patch is used to conD) The patch should be redundant to provide an unobstructed baffletruction is completed with a homograft valved conduit.

ncision, and pledgeted retraction sutures are placed on r


he ventriculotomy edges to facilitate exposure of theSD and the tricuspid valve apparatus (Fig 1A).The VSD is routinely enlarged by excision of a wedge

f the septal tissue anterosuperiorly using an 11 blade. Inddition, a large portion of infundibular septum beneathhe aortic valve is excised to provide an unobstructedath for baffle reconstruction between the LV and theorta (Fig 1B). In small infants, exposure of the septum isacilitated by passing a Hagar dilator through an openingn the aorta and through the VSD into the LV. By tiltinghe Hagar anteriorly, exposure is enhanced to allow safend effective VSD enlargement.A redundant cylindrical patch, usually created from a

ascular graft that is opened longitudinally, is used toonstruct the baffle. The baffle construction is usuallyade with running sutures to the right ventricular tissue,

einforced by pledgeted mattress sutures as needed (FigsC and D). Before closure of the superior margin of theatch, the baffle is inspected and sized with a Hagarilator. If there is any concern regarding the adequacy of

he baffle size, the ascending aorta is opened and the

ncision is placed away from epicardial vessels and retraction suturesicuspid valve apparatus. (B) The VSD is routinely enlarged by exci-addition, excision of a large portion of infundibular septum beneatht the baffle with running sutures to the right ventricular tissue.en the left ventricle and aorta. (E) Right ventricle outflow recon-

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139Ann Thorac Surg ALSOUFI ET AL2009;88:137–43 RASTELLI PROCEDURE FOR D-TGA

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A small oblique incision in the right atrium is madend the atrial septal defect is closed. The distal mainulmonary artery is opened longitudinally and the inci-ion is carried into the proximal left pulmonary artery.he mobilized pulmonary artery (and subsequently theonduit) is preferably positioned to the left of the ascend-ng aorta. The distal conduit anastomosis is usually madeith the heart perfused and beating after air is removed

nd the cross-clamp is removed, except in smaller infantsn whom it can be performed while the aortic cross-clamps still in place.

Rewarming is completed as the proximal anastomosiss performed and cardiopulmonary bypass is shortlyerminated after the completion of the proximal conduitnastomosis (Fig 1E). Intraoperative transesophagealchocardiography is routinely used to assess the repair.

ollow-Upate outcomes were determined from recent office visitst our center and from direct correspondence with pa-ients’ families. Mean follow-up was 8.3 � 6.1 yearsrange, 1.3 to 17 years) and was complete in all but 2atients who have left the country and in whom partial

ollow-up was available.

tatistical Analysisll the data were analyzed with SAS 9 software (SAS

nstitute, Inc, Cary, NC). Data are presented as frequency%), median with range, or mean � SD, as appropriate,ith the number of nonmissing values indicated. Esti-ates for survival, long-term freedom from reoperation,

ermanent pacemaker insertion, and LVOTO were madey the Kaplan-Meier method. Differences between sur-ival curves were evaluated with the log-rank statistic.ox regression was used to determine the independentredictors of late outcomes. The appropriateness of vari-ble transformations was determined by means of uni-ariate analysis. Variables with a univariate value of p �.05 or those with known biologic significance but failingo meet this critical c2 level were submitted to multiva-iable models.

ig 2. Freedom from permanent pacemaker implantation after the
castelli operation.

esults

he study included 36 consecutive patients (21 boys, 15irls) with d-TGA, VSD and PS. Median age was 2.4 yearsrange, 111 days to 8.3 years). Pulmonary stenosis wasresent in 31 patients and pulmonary atresia in 5. Twenty-

wo patients had undergone a previous aortopulmonaryhunt, and 6 had a previous atrial septectomy. Additionalardiac anomalies included 3 with multiple VSDs, 2 withextrocardia, and 1 patient each with total anomalousulmonary venous connection, coarctation of the aorta,ommon atrium, and interrupted inferior vena cava.

Average cardiopulmonary bypass duration was 154 �6 minutes, and average aortic cross-clamp was 91 � 26inutes. Right ventricular outflow tract (RVOT) recon-

truction was performed with pulmonary homografts in5, aortic homografts in 10, and Contegra bovine jugularonduit in 1. Average conduit size was 19 mm (range, 17o 22 mm). Additional procedures included pulmonaryrtery patch angioplasty im 5, tricuspid valve repair in 2,nd coarctation repair, total anomalous pulmonary ve-ous connection repair and common atrium septation inpatient each.No operative or late deaths occurred. Six patients

equired permanent pacemaker implantation for heartlock. Most were required within the first year after theastelli operation. Overall freedom from permanentacemaker implantation at 5 years was 82% (Fig 2). Theatient’s age was not a risk factor for permanent pace-aker requirement. The incidence of complete heart

lock decreased in the later half in our series, with only 1atient requiring a permanent pacemaker implantation.his is likely due to more careful VSD enlargement in thenterosuperior direction and more aggressive resectionf the infundibular septum, which may carry a lower

ncidence of injury to the conduction system.Time-related freedom from RV to pulmonary artery

onduit replacement in our series was 86% at 5 yearsnd 49% at 10 years (Fig 3). Most conduits were chan-ed because stenosis developed, although two conduit

ig 3. Freedom from right ventricle (RV) to pulmonary artery (PA)onduit change after the Rastelli operation.

hanges were required early for endocarditis.



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Average conduit survival was 4.95 years (range, 146ays to 9.6 years) and was 6.46 years if the two earlyeplacements for endocarditis were excluded. Four ofhose patients had undergone conduit dilatation andtent implantation before their conduit change. Subse-uent to conduit change, two patients required secondonduit replacement for valve stenosis.

Additional operations at time of conduit change wereequired in few patients: tricuspid valve repair in 3,ulmonary artery patch angioplasty in 2, closure ofesidual VSD in 1, and muscle resection for right mid-entricular obstruction in 1. No patients required sepa-ate reoperations for cardiac causes other than conduithange.

Several demographic, anatomic, and operative vari-bles were examined, and none was identified as aignificant factor for conduit replacement on multivari-ble analysis, likely due to small sample size and theultitude of the factors that can influence graft longevity.Follow-up echocardiograms were obtained and re-

iewed. No patients had any evidence of recurrentVOTO. The median gradient across the LVOT baffleas 5 mm Hg (range, 2 to 14 mm Hg), and in only 1atient did it exceed 10 mm Hg. The gradient was notigher in younger infants compared with older children.

n addition, no aortic regurgitation was evident in anyatient. Additional residual lesions on follow-up echo-ardiogram included small residual VSD in 2, mild tri-uspid valve regurgitation in 3, and pulmonary arteryranch stenosis in 3. In addition, 8 of the current ho-ografts had evidence of mild stenosis with or without

egurgitation, signaling potential need for conduit re-lacement in the future.The LV function was normal in 33 patients and moder-

tely depressed in 3. These 3 patients were all aged olderhan 4 years when they underwent the Rastelli repair.

At the last follow-up, 92 patients were in New York Heartssociation functional class I or II. None of the remainingatients required orthotopic heart transplantation.

omment

he Rastelli procedure was first introduced in 1969 andoon became the conventional surgical management foratients with d-TGA, VSD, and PS [1, 2]. Nonetheless,ublished clinical data have shown the long-term resultsf the Rastelli procedure are far from optimal, withiminished long-term survival, depressed ventricular

unction, and increased reintervention on the RVOT orVOT [3–6].

arly Deatharly operative survival has changed dramatically during

he past 40 years. In the series from Mayo Clinic [5], earlyortality decreased from 24.4% from years 1968 to 1977

o 4.8% from 1988 to 1997. The Boston group [4] similarlyeported 30-day mortality of 11% from 1980 to 1989 and% from 1990 to 1998, with no deaths in the last 7 years ofheir report. Our operative mortality has been zero,
hich is in line with the current reported operative L

ortality of less than 5% for various procedures toorrect this anomaly [8–11]. This superior operative sur-ival is mainly due to improvement in technical experi-nce with this complex biventricular repair, in perfusionnd myocardial preservation strategies, and in postoper-tive care of those children in the intensive care unit.

eft Ventricular Outflow Tract Obstructionate LVOTO is an important late complication after theastelli procedure [4, 7]. The obstruction is usually at

he level of the VSD or beneath the intracardiac baffle.he mechanisms likely responsible for this complicationre related to failure of the VSD or of the baffle pathwayo enlarge as the patient grows. Other possible explana-ions include reduced LV volume load after the repairesulting in a restrictive VSD or development of RVypertension leading to septal hypertrophy and a restric-

ive VSD [4, 5, 7].The reported reoperation risk for recurrent LVOTO

fter the Rastelli operation varies. Kreutzer and col-eagues [4] from Boston reported an 84% freedom fromVOT reintervention at 15 years. In addition, the cause ofarly death was related to residual LVOTO in 3 patients.n contrast, Dearani and colleagues [5] from Mayo Clinicoted a 99% freedom from LVOT reintervention in hos-ital survivors, although they did not comment on theresence of LVOTO in the patients who died. The VSDas routinely enlarged anterosuperiorly in less than halff the patients in the Boston series compared with a

ower threshold to enlarge the VSD anterosuperiorly inddition to excision of a large portion of the infundibulareptum beneath the aortic valve in the Mayo Clinic series4, 5]. This approach was adopted at our institution ande have not seen echocardiographic evidence of any

ignificant gradient across the LVOT and thus no LVOTeintervention has been required to date.

Kreutzer and colleagues [4] reported that most LVOTeinterventions were in the first 5 years after the Rastelliperation (freedom of 88% at 5 years, 84% at 15 years).ime to LVOTO reintervention was somewhat shorter for

nfants aged younger than 1 year at the Rastelli repair [4].lthough our follow-up in the current series is shorter

han that in their article, the freedom from LVOTO in ouratients is promising considering that the majority ofbstructions were evident early in their series.An important variation on the theme of Rastelli was

ublished by LeCompte and colleagues [12] in 1982. Thisperation was called “reparation a l’etage ventriculaire”r the REV procedure. In a departure from the classicastelli operation, the infundibular septum is totally

esected, providing a short and direct tunnel from the LVo the aorta, thus avoiding the potential formation of aubaortic LVOTO. In addition, the pulmonary artery wasirectly connected to the RV without the use of a conduit.eintervention for LVOTO was required in 2 of 111atients; this similarly small number confirms the effi-acy of aggressive VSD enlargement plus resection of thenfundibular septum in reducing the risk of recurrent
VOTO [9, 12, 13].


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Aortic translocation and biventricular outflow tractonstruction, the Nikaidoh operation, was proposed asn alternative to the Rastelli operation because it pro-ides a more normal, better aligned RVOT and LVOT14]. This procedure is technically challenging, such thatt has not been widely adopted despite a recent increasednterest by many groups. Yeh and colleagues [11] re-orted midterm outcomes in 19 patients after the Ni-aidoh operation. No LVOTO was evident, and no pa-ient had aortic insufficiency (AI) that was more than mildmild in 9, trace in 3, and absent in 6) [11]. Conversely,

orell and colleagues [10, 15] reported midterm out-omes in 21 patients after a modified Nikaidoh proce-ure. LVOTO was similarly eliminated, although half of

he patients had mild AI; at least 3 had moderate AI, withrequiring reoperation for severe AI.The higher incidence in the later study may be related

o technical differences as discussed by Yeh and Ni-aidoh. They selectively reimplant only right coronaries,ave not had to implant left coronaries, do not divide thescending aorta, do not perform a LeCompte maneuver,nd operate on slightly older patients [11] compared withorell and colleagues. In comparison, the risk of AI is

ery small in patients undergoing the Rastelli operation,nd none of the patients in our series had evidence of AIn follow-up echocardiograms.In brief, our current study emphasizes findings from

ther reports that routine aggressive VSD enlargementith anterosuperior incision and resection of the infun-ibular septum mitigate the risk of LVOTO analogous to

he more complex aortic translocation operation. None-heless, the Nikaidoh procedure remains indicated inatients with anatomic contraindications to the Rastellirocedure, such as those with a small RV, remote VSD, orstraddling tricuspid valve [10, 11, 14, 15].The incidence of complete heart block requiring pace-aker requirement in the Mayo Clinic series was 11%

ompared with 3% in the Boston group, excluding pa-ients who died with complete heart block before pace-

aker implantation [4, 5]. This may be related to theower threshold of VSD enlargement in the Mayo Clinicatients. We have had a similarly concerning high inci-ence of complete heart block and pacemaker implanta-

ion in our patients that may limit the value of thispproach. Nonetheless, we believe that a more carefulnterosuperior enlargement of the VSD and aggressiveesection of the infundibular septum may decrease theisk of this complication, and that was noted in our moreecent experience with decreased incidence of perma-ent complete heart block. We speculate that with thispproach, the risk of complete heart block can be furthereduced similar to that in patients undergoing the REVperation in which the incidence of permanent pace-aker implantation was very low [8, 9, 13].

ight Ventricular Outflow Tract Obstructionimilar to previously published reports, a high incidencef RVOT reoperation for conduit change was docu-ented in our series [3–5]. Our study is not powered to

ssess the risk factors for conduit replacement, but recent t


dvances in our knowledge of the management of RVOTre noteworthy.Valveless RVOT reconstruction such as in the REV

peration or the original Nikaidoh procedure has beenssociated with diminished risk for RVOT reoperation.onetheless, the long-term results of free pulmonary

egurgitation are of major concern. Earlier reoperationay be required, especially in patients with branch

ulmonary artery stenosis, which is frequent in thisardiac pathology and may increase the severity of pul-onary regurgitation and its effect on RV dilatation and

ysfunction [8, 9, 11, 13, 15].The choice of conduit for RVOT reconstruction re-ains controversial. Dearani and colleagues [5, 16] re-

orted improved conduit survival in those who receivedioprosthetic valve conduits compared with homografts.onetheless, because we tend to operate earlier on those

omplex patients, the role of those valved conduits isimited. Moreover, proper conduit selection—and conse-uently graft survival—may improve in the current era ase learn from several recent reports that have shed some

ight on factors that may increase graft survival such ashe proper sizing between Z score �1 and �3, valve type,nd blood type, among others [16–18].Finally, an important advance in the management of

ecurrent RVOTO is the evolution of techniques forercutaneous pulmonary valve implantation. Recent ex-erience with this technique is encouraging and mayecrease the risk for redo sternotomy for conduit changend may change the philosophy of our approach toecurrent RVOTO in the near future [19].

entricular Function and Late Survivalhe largest available studies in the literature showediminished long-term survival to between 50% and 60%t 20 years after the Rastelli operation [4, 5]. Despitehorter follow-up in the current series, the lack of lateortality to date is encouraging. Nonetheless, 3 patientsho underwent the procedure at a relatively older ageave persistent ventricular dysfunction [6]. Improvedostoperative care, surgical, and perfusion techniquesay have contributed to diminished late attrition, but

arly repair for those complex disorders, before develop-ent of ventricular changes that may persist despite

uccessful biventricular repair, may be an importantactor influencing late ventricular function and patienturvival. A study by Graham and colleagues [6] demon-trated abnormal elevated mean end-systolic stress andV mass and diminished contractile function after theastelli procedure. The risk of development of lateVOTO, historically higher in patients undergoing oper-tions at younger age, has been mitigated with routineggressive VSD enlargement, earlier biventricular repairs advocated in an effort to alleviate the effects of in-reased exposure to hypoxia, obstruction, and volumeverloading over a prolonged period on the function ofhe LV.

The risk of late arrhythmias and sudden death after theastelli operation is well documented [4, 5]. These pa-

ients are usually followed up at our arrhythmia clinic



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here Holter monitoring and exercise testing are donevery other year. No late tachyarrhythmias have devel-ped in the patients in our series; however, longerollow-up is necessary because those arrhythmias mayontinue to arise late after the operation [4, 5].

Early and midterm results after the Rastelli operationave improved. The risk of recurrent LVOTO has beenitigated by routine enlargement of the VSD and exci-

ion of the infundibular septum. Neutralization of youngge as a risk factor for development of recurrent LVOTOnd the presence of persistent ventricular dysfunctionespite successful operation especially in older childrent time of biventricular repair support earlier definiteepair to avoid the sequelae of hypoxia and chronicressure and volume load on the myocardium. There-

ore, our current policy is to perform the Rastelli opera-ion when the child’s weight is about 8 kg. The concern-ng incidence of complete heart block can be diminishedy careful anterosuperior incisions and dependence on

nfundibular resection for VSD enlargement. Surgicallternatives using valveless direct RVOT reconstructiontrategies such as the REV or Nikaidoh procedures mayffer an advantage with regards to RVOT reinterventionisk.

e thank Nada Khoja Bakka for her help with the illustrationsn this manuscript.

eferences

1. Rastelli GC. A new approach to the “anatomic” repair oftransposition of the great arteries. Mayo Clin Proc 1969;44:1–12.

2. Rastelli GC, Wallace RB, Ongley PA. Complete repair oftransposition of the great arteries with pulmonary stenosis:A review and report of a case corrected by using a newsurgical technique. Circulation 1969;39:83–95.

3. Moulton AL, de Leval MR, Macartney FJ, Taylor JF, Stark J.Rastelli procedure for transposition of the great arteries,ventricular septal defect and left ventricular outflow tractobstruction: early and late results in 41 cases (1971–1978). BrHeart J 1981;45:20–8.

4. Kreutzer C, DeVive J, Oppido G, et al. Twenty-five yearexperience with Rastelli repair for transposition of the greatarteries. J Thorac Cardiovasc Surg 2000;120:211–23.

5. Dearani JA, Danielson GK, Puga FJ, Mair DD, Schleck CD.Late results of the Rastelli operation for transposition of thegreat arteries. Semin Thorac Cardiovasc Surg Pediatr Card
Surg Annu 2001;4:3–15.
ho require permanent pacing after a Rastelli operation are at risk

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6. Graham TP, Franklin RC, Wyse RK, Gooch V, Deanfield JE.Left ventricular wall stress and contractile function in trans-position of the great arteries after the Rastelli operation.J Thorac Cardiovasc Surg 1987;93:775–84.

7. Rychik J, Jacobs ML, Norwood WI. Early changes in ventric-ular geometry and ventricular septal defect size followingRastelli operation or intra-ventricular baffle repair forconotruncal anomaly: a cause for development of sub-aorticstenosis. Circulation 1994;90:II-13–9.

8. Lee JR, Lim HG, Kim YJ, et al. Repair of transposition of thegreat arteries, ventricular septal defect and left ventricularoutflow tract obstruction. Eur J Cardiothorac Surg 2004;25:735–41.

9. Pretre R, Gendron G, Tamisier D, Vernant F, Sidi D, VouheP. Results of the Lecompte procedure in malposition of thegreat arteries and pulmonary obstruction. Eur J Cardiotho-rac Surg 2001;19:283–9.

0. Morell VO, Jacobs JP, Quintessenza JA. Aortic translocationin the management of transposition of the great arteries withventricular septal defect and pulmonary stenosis: resultsand follow-up. Ann Thorac Surg 2005;79:2089–92.

1. Yeh T Jr, Ramaciotti C, Leonard SR, Roy L, Nikaidoh H. Theaortic translocation (Nikaidoh) procedure: midterm resultssuperior to the Rastelli procedure. J Thorac Cardiovasc Surg2007;133:461–9.

2. Lecompte Y, Neveux JY, Leca F, et al. Reconstruction of thepulmonary outflow tract without prosthetic conduit. J ThoracCardiovasc Surg 1982;84:727–33.

3. Rubay J, Lecompte Y, Batisse A, et al. Anatomic repair ofanomalies of ventriculo-arterial connection (REV). Results ofa new technique in cases associated with pulmonary outflowtract obstruction. Eur J Cardiothorac Surg 1988;2:305–11.

4. Nikaidoh H. Aortic translocation and biventricular outflowtract reconstruction: a new surgical repair for transpositionof the great arteries associated with a ventricular septaldefect and pulmonary stenosis. J Thorac Cardiovasc Surg1984;88:365–72.

5. Morell VO, Wearden PD. Technique of aortic translocationfor the management of transposition of the great arterieswith a ventricular septal defect and pulmonary stenosis.Operative Techniques in Thoracic and Cardiovascular Sur-gery 2008;13:181–7.

6. Dearani JA, Danielson GK, Puga FJ, et al. Late follow-up of1095patients undergoing operation for complex congenitalheart disease utilizing pulmonary ventricle to pulmonaryartery conduits. Ann Thorac Surg 2003;75:399–411.

7. Caldarone CA, McCrindle BW, Van Arsdell GS, et al. Inde-pendent factors associated with longevity of prosthetic pul-monary valves and valved conduits. J Thorac CardiovascSurg 2000;120:1022–31.

8. Karamlou T, Blackstone EH, Hawkins JA, et al. Can pulmo-nary conduit dysfunction and failure be reduced in infantsand children less than age 2 years at initial implantation?J Thorac Cardiovasc Surg 2006;132:829–38.

9. Nordmeyer J, Coats L, Bonhoeffer P. Current experiencewith percutaneous pulmonary valve implantation. Semin
Thorac Cardiovasc Surg 2006;18:122–5.
ISCUSSION

R MARSHALL JACOBS (Newtown Square, PA): I want toompliment you on a very nice presentation, and I think it isery important to reevaluate the role of the Rastelli operation asou have done. You commented very candidly on the issues ofeart block and pacemaker requirement. While I think that we allcknowledge that the need for a pacemaker complicates the life ofhe patient and can be a significant quality of life factor, there is alsovidence from previously published studies that those patients

or progressive LV [left ventricular] dysfunction over time, so itecomes a serious problem for multiple reasons.In comparing this procedure to alternative procedures, it

eems to me that the risk of acquiring heart block in thisperation is related either to the placement of sutures for theaffle, which would be a risk shared by this procedure andlternative procedures, or to the technique of septal resection tonlarge the VSD [ventricular septal defect]. Would you please
omment, and tell us whether over the course of this series you


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ave changed your approach in terms of the details of septalesection to enlarge the VSD.

R ALSOUFI: As stated, permanent pacemaker requirementas a major concern. As shown in the presentation, the inci-ence of complete heart block decreased in the later part of ourxperience. We believe that a more careful anterosuperiornlargement of the VSD and aggressive resection of the infun-ibular septum may have helped decreasing the risk of thisomplication as a result of avoiding septal incision in proximityo the conduction system. Existing literature may support ourndings; in centers where they routinely enlarge the VSDnterosuperiorly such as the Mayo Clinic, permanent pace-aker implantation was required in about 11% of survivors,hile it was required in only 3% of survivors in the Boston

eries, where they selectively enlarge the VSD, and finally it wasequired in less than 2% of patients in Lecompte’s series whereSD enlargement is usually done by resecting the infundibular

eptum.

R PIGULA (Boston, MA): Can you tell me again how long theollow-up was of these patients? And in those patients, pulmo-ary atresia, I think, is clearly understood. But those withtenosis that you decided needed a Rastelli rather than atraightforward arterial switch operation, some of these patientshat will present with some degree of left ventricular outflowract narrowing under that physiology are still able to bewitched using a standard operation. So how did you decide?

R ALSOUFI: All those patients were assessed at time of theirnitial presentation by the cardiologists and the cardiac surgeonsnd were thought not to be candidates to undergo the arterialwitch operation. The decision to receive initial palliation is clearhen the presenting lesion is pulmonary atresia; however, when

here is pulmonary stenosis, the decision about their candidacyo receive the arterial switch operation depends on the size ofhe pulmonary valve annulus, the status of the cups, and theevels of obstruction. I cannot comment on how many patientsuring the same time period presented to our institution with-transposition of the great arteries, VSD, and pulmonary ste-osis and underwent a switch operation, but those usually havereasonable size pulmonary valve annulus, normal cusps and

o significant subvalvular obstruction. I’m sorry, what was yourther question?

R PIGULA: The other question was the duration of theollow-up. But also, was there a Z score that you have in mind?guess I am just trying to get at how the decision was made,astelli vs in those borderline cases admittedly.

R ALSOUFI: I don’t have the information about the Z score of
hose patients with TGA [transposition of the great arteries], a

SD, and pulmonary stenosis who had undergone the arterialwitch operation successfully at our institution. Again, thosesually would have normal cusps and no significant tunnel-likeubvalvar obstruction. Of note, we have published our experi-nce with the arterial switch operation in patients with bicuspidulmonary valve and that is not a contraindication for the switchperation if the cusps are normal. If the diagnosis is made in theeonatal period, the child would undergo the switch operations a palliative shunt plus minus septectomy based on the naturef the obstruction of the left ventricular outflow tract.The average follow-up in our series was about 8 years. This

ollow-up is relatively shorter compared to larger previoustudies from Boston group or the Mayo Clinic. Nonetheless, inerms of recurrent LV outflow tract obstruction risk, if you lookt the Boston series, you see that their 5-year freedom fromVOT obstruction was 88% and their 15-year freedom was 84%,o the majority of obstructions were evident within the first 3 toyears following operation. So even though our follow-up is nots long, we believe that our finding with regards to eliminationf LVOT obstruction risk is very encouraging considering thatistorically those complications were evident in the early fewears following surgery.

R PIGULA: Well, the reason I am trying to pin you down aittle bit on it is we have gone back and looked at these patientsith left ventricular outflow tract obstructions in the transposi-

ion subgroup and found that a fair number of these, evenith—admittedly it is a complex issue—but with Z scores of theulmonary valve of �2.5 in some cases that that was suitablend actually, compared to the Rastelli, that was a preferentialtrategy in terms of left ventricular outflow tract lesions in theuture. So I think that there is a little bit of a gray area there inerms of which strategy over the long term is going to be the

ost sustainable.

R AL-HALEES (Riyadh, Saudi Arabia): I am the surgeon in theroup. These patients were clearly nonswitchable. They had badulmonary valves, plus minus subvalvular obstruction. All theseatients were not candidates for arterial switch.

R JOSEPH FORBESS (Dallas, TX): One thing that I have gonehrough with my thinking on those cases, Frank, is that this isnalogous to interrupted aortic arch with VSD, because the VSDs essentially the same as an interrupted aortic arch a posterior

alalignment VSD. With a show of hands, would people do awitch on a 3-kg child with a 5.5-mm bicuspid pulmonary valvef the leaflets were fairly mobile?

(Show of hands.)So not that many, but some. I would have to agree that

eaddressing the left ventricular outflow tract on a patient after
rterial switch is clearly not an easy operation.


DOI: 10.1016/j.athoracsur.2009.03.099 2009;88:137-143 Ann Thorac Surg

Canver, Ziad Bulbul, Avedis Kalloghlian and Zohair Al-Halees Bahaaldin Alsoufi, Abid Awan, Ahmad Al-Omrani, Mamdouh Al-Ahmadi, Charles C.

Obstruction RiskInfundibular Septum Diminishes Recurrent Left Ventricular Outflow Tract

The Rastelli Procedure for Transposition of the Great Arteries: Resection of the

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