Rastelli operation for transposition of the great arteries with ventricular septal defect and pulmonary stenosis

John Brown, Mark Ruzmetov, Daniel Huynh, Mark Rodefeld, Mark Turrentine, Andrew C. Fiore

Research output: Contribution to journalArticle

23 Citations (Scopus)

Abstract

Background The optimal surgical treatment of patients with transposition of the great arteries, ventricular septal defect, and pulmonary stenosis is controversial. Although the Rastelli operation has been standard surgical management of this lesion, aortic root translocation with right ventricular outflow tract (RVOT) reconstruction (Nikaidoh) and the pulmonary artery translocation (Lecompte) or REV (rparation a l'tage ventriculaire) are surgical alternatives more recently introduced to treat this complex lesion. This report reviews our 20-year experience with the Rastelli procedure and attempts to compare our outcomes with those recently published using the Nikaidoh and REV procedures. Methods Between 1988 and 2008, 40 patients (median age, 4 years; range, 9 months to 17 years) underwent Rastelli operation at our institutions. The RVOT was obstructed in 32 and atretic in 8. Follow-up was available for all but one patient (mean follow-up, 8.6 ± 5.6 years). The RVOT was reconstructed with homograft (n = 25), bovine jugular vein (n = 8), nonvalved Dacron tube (n = 5), or a porcine valved conduit (n = 2). Two patients required a pacemaker. Results There were no early, but three late deaths and one heart transplantation 12 years postoperative the Rastelli operation. Kaplan-Meier survival was 93% at 5, 10, and 20 years. Univariate risk factors for death or transplantation included surgery before 1998 (p = 0.03) and concomitant noncardiac anomalies (p = 0.001). Sixteen patients (40%) had reoperation for right ventricular-pulmonary artery conduit stenosis (mean, 7.8 ± 3.8 years) without mortality. Freedom from conduit replacement was 86%, 74%, 63%, and 59% at 5, 10, 15, and 20 years, respectively. Multivariate analysis revealed that the risk factors of conduit replacement were younger age at operation (p = 0.001) and surgery before 1998 (p < 0.001). Two patients (5%) required reoperation for left ventricular outflow tract obstruction. At follow-up, there were no sudden unexplained deaths, and New York Heart Association functional class is I or II. Conclusions The Rastelli procedure is a low-risk operation with regard to early and late mortality and reoperation for left ventricular outflow tract obstruction. Conduit change operations will be required in most patients regardless of the technique of repair, but currently can be performed with low morbidity and mortality. These midterm outcomes after the Rastelli operation should serve as a basis for comparison with surgical alternatives more recently introduced for transposition of the great arteries and ventricular septal defect with RVOT obstruction.

Original languageEnglish
Pages (from-to)188-194
Number of pages7
JournalAnnals of Thoracic Surgery
Volume91
Issue number1
DOIs
StatePublished - Jan 2011

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Transposition of Great Vessels
Pulmonary Valve Stenosis
Ventricular Heart Septal Defects
Ventricular Outflow Obstruction
Reoperation
Mortality
Polyethylene Terephthalates
Jugular Veins
Heart Transplantation
Sudden Death
Arterial Switch Operation
Pulmonary Artery
Allografts
Swine
Multivariate Analysis
Transplantation
Morbidity
Survival

ASJC Scopus subject areas

  • Cardiology and Cardiovascular Medicine
  • Surgery
  • Pulmonary and Respiratory Medicine

Cite this

Rastelli operation for transposition of the great arteries with ventricular septal defect and pulmonary stenosis. / Brown, John; Ruzmetov, Mark; Huynh, Daniel; Rodefeld, Mark; Turrentine, Mark; Fiore, Andrew C.

In: Annals of Thoracic Surgery, Vol. 91, No. 1, 01.2011, p. 188-194.

Research output: Contribution to journalArticle

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abstract = "Background The optimal surgical treatment of patients with transposition of the great arteries, ventricular septal defect, and pulmonary stenosis is controversial. Although the Rastelli operation has been standard surgical management of this lesion, aortic root translocation with right ventricular outflow tract (RVOT) reconstruction (Nikaidoh) and the pulmonary artery translocation (Lecompte) or REV (rparation a l'tage ventriculaire) are surgical alternatives more recently introduced to treat this complex lesion. This report reviews our 20-year experience with the Rastelli procedure and attempts to compare our outcomes with those recently published using the Nikaidoh and REV procedures. Methods Between 1988 and 2008, 40 patients (median age, 4 years; range, 9 months to 17 years) underwent Rastelli operation at our institutions. The RVOT was obstructed in 32 and atretic in 8. Follow-up was available for all but one patient (mean follow-up, 8.6 ± 5.6 years). The RVOT was reconstructed with homograft (n = 25), bovine jugular vein (n = 8), nonvalved Dacron tube (n = 5), or a porcine valved conduit (n = 2). Two patients required a pacemaker. Results There were no early, but three late deaths and one heart transplantation 12 years postoperative the Rastelli operation. Kaplan-Meier survival was 93{\%} at 5, 10, and 20 years. Univariate risk factors for death or transplantation included surgery before 1998 (p = 0.03) and concomitant noncardiac anomalies (p = 0.001). Sixteen patients (40{\%}) had reoperation for right ventricular-pulmonary artery conduit stenosis (mean, 7.8 ± 3.8 years) without mortality. Freedom from conduit replacement was 86{\%}, 74{\%}, 63{\%}, and 59{\%} at 5, 10, 15, and 20 years, respectively. Multivariate analysis revealed that the risk factors of conduit replacement were younger age at operation (p = 0.001) and surgery before 1998 (p < 0.001). Two patients (5{\%}) required reoperation for left ventricular outflow tract obstruction. At follow-up, there were no sudden unexplained deaths, and New York Heart Association functional class is I or II. Conclusions The Rastelli procedure is a low-risk operation with regard to early and late mortality and reoperation for left ventricular outflow tract obstruction. Conduit change operations will be required in most patients regardless of the technique of repair, but currently can be performed with low morbidity and mortality. These midterm outcomes after the Rastelli operation should serve as a basis for comparison with surgical alternatives more recently introduced for transposition of the great arteries and ventricular septal defect with RVOT obstruction.",
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AU - Fiore, Andrew C.

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N2 - Background The optimal surgical treatment of patients with transposition of the great arteries, ventricular septal defect, and pulmonary stenosis is controversial. Although the Rastelli operation has been standard surgical management of this lesion, aortic root translocation with right ventricular outflow tract (RVOT) reconstruction (Nikaidoh) and the pulmonary artery translocation (Lecompte) or REV (rparation a l'tage ventriculaire) are surgical alternatives more recently introduced to treat this complex lesion. This report reviews our 20-year experience with the Rastelli procedure and attempts to compare our outcomes with those recently published using the Nikaidoh and REV procedures. Methods Between 1988 and 2008, 40 patients (median age, 4 years; range, 9 months to 17 years) underwent Rastelli operation at our institutions. The RVOT was obstructed in 32 and atretic in 8. Follow-up was available for all but one patient (mean follow-up, 8.6 ± 5.6 years). The RVOT was reconstructed with homograft (n = 25), bovine jugular vein (n = 8), nonvalved Dacron tube (n = 5), or a porcine valved conduit (n = 2). Two patients required a pacemaker. Results There were no early, but three late deaths and one heart transplantation 12 years postoperative the Rastelli operation. Kaplan-Meier survival was 93% at 5, 10, and 20 years. Univariate risk factors for death or transplantation included surgery before 1998 (p = 0.03) and concomitant noncardiac anomalies (p = 0.001). Sixteen patients (40%) had reoperation for right ventricular-pulmonary artery conduit stenosis (mean, 7.8 ± 3.8 years) without mortality. Freedom from conduit replacement was 86%, 74%, 63%, and 59% at 5, 10, 15, and 20 years, respectively. Multivariate analysis revealed that the risk factors of conduit replacement were younger age at operation (p = 0.001) and surgery before 1998 (p < 0.001). Two patients (5%) required reoperation for left ventricular outflow tract obstruction. At follow-up, there were no sudden unexplained deaths, and New York Heart Association functional class is I or II. Conclusions The Rastelli procedure is a low-risk operation with regard to early and late mortality and reoperation for left ventricular outflow tract obstruction. Conduit change operations will be required in most patients regardless of the technique of repair, but currently can be performed with low morbidity and mortality. These midterm outcomes after the Rastelli operation should serve as a basis for comparison with surgical alternatives more recently introduced for transposition of the great arteries and ventricular septal defect with RVOT obstruction.

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