The rastelli procedure for transposition of the great arteries: resection of the infundibular septum diminishes recurrent left ventricular outflow tract obstruction risk

Ann Thorac Surg. 2009 Jul;88(1):137-42; discussion 142-3. doi: 10.1016/j.athoracsur.2009.03.099.


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.

MeSH terms

  • Abnormalities, Multiple / diagnostic imaging
  • Abnormalities, Multiple / mortality
  • Abnormalities, Multiple / surgery
  • Analysis of Variance
  • Cardiac Surgical Procedures / adverse effects
  • Cardiac Surgical Procedures / methods*
  • Child
  • Child, Preschool
  • Cohort Studies
  • Female
  • Follow-Up Studies
  • Heart Septal Defects, Ventricular / diagnostic imaging
  • Heart Septal Defects, Ventricular / mortality
  • Heart Septal Defects, Ventricular / surgery*
  • Humans
  • Infant
  • Infant, Newborn
  • Kaplan-Meier Estimate
  • Logistic Models
  • Male
  • Proportional Hazards Models
  • Pulmonary Valve Stenosis / diagnostic imaging
  • Pulmonary Valve Stenosis / mortality
  • Pulmonary Valve Stenosis / surgery*
  • Risk Assessment
  • Sensitivity and Specificity
  • Survival Analysis
  • Time Factors
  • Transposition of Great Vessels / diagnostic imaging
  • Transposition of Great Vessels / mortality
  • Transposition of Great Vessels / surgery*
  • Treatment Outcome
  • Ultrasonography
  • Ventricular Outflow Obstruction / prevention & control*