Br Heart J: first published as 10.1136/hrt.45.1.20 on 1 January 1981. Downloaded from Br Heart J 1981; 45: 20-8 Rastelli procedure for transposition of the great arteries, ventricular septal defect, and left ventricular outflow tract obstruction* Early and late results in 41 patients (1971 to 1978) A L MOULTON,t M R DE LEVAL, F J MACARTNEY, J F N TAYLOR, J STARK From the Thoracic Unit, The Hospital for Sick Children, Great Ormond Street, London SUMMARY Forty-one children with transposition of the great arteries, ventricular septal defect, and left ventricular outflow tract obstruction underwent a Rastelli operation between 1971 and 1978. A homograft valve preserved in an antibiotic solution and extended with a Dacron tube was the conduit of choice. Alternatively, conduits with porcine heterografts or valves constructed from calf pericardium were used. They were positioned to the left of the aorta whenever possible. The intraventricular tunnel from the left ventricle to the aorta was constructed from Dacron velour. There were four early and seven late deaths. The last 13 consecutive patients have survived. Early deaths were related to unfavourable anatomy, conduit compression, and sepsis. Residual ventricular septal defects and postoperative infection were the main factors contributing to the late deaths. The combination oftransposition ofthe greatarteries, obstruction. He suggested diverting left ventricular http://heart.bmj.com/ ventricular septal defect, and left ventricular outflow output to the aorta by occluding the proximal tract obstruction is uncommon. It occurred in 97 pulmonary artery and creating a conduit within (0-67%) of the 15 104 patients with congenital the right ventricle which would carry blood ejected heart disease reviewed by Keith and colleagues'; through the ventricular septal defect into the aorta. but significant left ventricular outflow tract ob- Right ventricular flow would be carried to the struction occurred in 28 to 31 per cent of patients distal pulmonary trunk by means of an external with transposition of the great arteries plus ventri- aortic homograft conduit. This achieved complete cular septal defect.2 3 Early attempts to resect the bypass of left ventricular outflow tract obstruction on September 27, 2021 by guest. Protected copyright. left ventricular outflow tract obstruction in com- and an anatomical as well as physiological correction bination with a Mustard procedure and closure of (Fig. la-c). the ventricular septal defect usually failed to relieve The purpose of this paper is to review the obstruction completely.4-6 complete series of patients who have undergone After the first clinical use of an unvalved peri- this type of operation for these three anomalies cardial tube as an extracardiac conduit,7 the at The Hospital for Sick Children, Great Ormond experimental work of Arai and colleagues,8 and the Street, London. first clinical application of an aortic homograft as a conduit,9 Rastelli'0 introduced a new procedure Subjects for the treatment of patients with the combination of transposition of the great arteries, ventricular Between 1971 and 1978, 41 children underwent septal defect, and left ventricular outflow tract Rastelli's operation for transposition of the great arteries, ventricular septal defect, and left ventricular * This work was supported in part by a British Heart Foundation outflow tract obstruction (some of these children grant. were subjects of previous reports" 12). There were t Present address: Division of Thoracic and Cardiovascular Surgery, 30 male and 11 female in the University of Maryland Hospital, 22 S. Greene Street, Baltimore, subjects group, ranging Maryland 21201, USA. in age from 2 years 3 months to 14 years 10 months 20 Br Heart J: first published as 10.1136/hrt.45.1.20 on 1 January 1981. Downloaded from Early and late results of Rastelli procedure 21 Ao PA Ao PA PA CONDUIT aI *.c Fig. la, b, c Principle of Rastelli's operation for transposition of the great arteries, associated with ventricular septal defect and left ventricular outflow tract obstruction. Ao, aorta; PA, pulmonary artery; RV, right ventricle; LV, left ventricle; VSD, ventricular septal defect; LVOTO, left ventricular outflow tract obstruction. (median 7 years 9 months). At the time of operation preserving nutrient antibiotic solution, containing: the children weighed from 12-5 kg to 50 kg (median medium 199 with no sodium bicarbonate (10 ml), 20 3 kg). All patients were cyanotic at the time of preheated "Cals" serum No. 1 (8 ml), 4A4 per cent operation. Aortic oxygen saturations were 55 to 88 sodium bicarbonate (5 ml), sterile distilled water per cent (median 78%) and haemoglobin levels (77 ml), nystatin (250 000 units in 10 ml), methi- 11 4 to 24 8 g/100 ml (median 19 69 g/lOO ml). cillin (1000 mg 1-5 ml), erythromycin 600 mg in Thirty-three patients had undergone previous 12 ml, gentamicin 400 mg in 10 ml, and strepto- palliative procedures (Table 1). Some patients mycin 20 000 units. had one or more operations. One 25-year-old child The coronary ostia of the homograft are over- underwent a Mustard operation with closure of sewn, the mitral valve and adjacent ventricular ventricular septal defect and attempted relief of muscle trimmed, and a Dacron tube of matching http://heart.bmj.com/ left ventricular outflow tract obstruction. Because diameter is then anastomosed to the "ventricular" of severe postoperative heart failure he required end of the homograft. If a suitable homograft is reoperation and a Rastelli procedure was success- not available, we use the Hancock conduit (Dacron fully performed. tube with a gluteraldehyde-preserved porcine valve). Other alternatives are pericardial or dura- OPERATIVE TECHNIQUE mater valves inserted into the Dacron tube. The principle of the technique described in The aorta is cannulated close to the origin of Rastelli's original paper has been followed. After the innominate artery with a right-angled metal on September 27, 2021 by guest. Protected copyright. a median sternotomy, any functioning shunts, the cannula. Right angled Rygg cannulae are introduced ductus arteriosus (if patent), and proximal pul- through the right atrial appendage and the right monary arteries are dissected. The conduit is atrium just above the inferior vena cava. Pre-existing prepared before establishing cardiopulmonary by- shunts are occluded. A Waterston shunt is either pass and a Dacron portion preclotted. At present, we compressed or the pulmonary artery is snared prefer a fresh aortic homograft preserved in an on either side of the shunt; a Potts anastomosis is antibiotic solution. The homograft is obtained as occluded by digital pressure through the left soon as possible after death. It is placed in a valve- pulmonary artery; Blalock-Taussig shunts or persistent ductus arteriosus are ligated before cardiopulmonary bypass is established. Cardio- Table 1 Previous operations pulmonary bypass with a flow of 2-4 1/min per m2 is used and the perfusate cooled to 20 to 250C. The None 8 left ventricle is vented through the left atrium or Pulmonary artery banding 2 the left ventricular The aorta is Balloon atrial septostomy 13 through apex. Blalock-Hanlon septectomy 10 cross-clamped and cold (4°C) cardioplegic solution Blalock-Taussig shunt 24 containing St. Thomas's solution13 is infused into Other aortopulmonary shunts 5 the aortic root until the myocardial temperature is Br Heart J: first published as 10.1136/hrt.45.1.20 on 1 January 1981. Downloaded from 22 Moulton, de Leval, Macartney, Taylor, Stark lowered to 8 to 12°C. The right atrium is opened AO and cardioplegic solution partly aspirated with a discard sucker. The pericardial cavity is also filled with the cold solution. When the nasopharyn- geal temperature falls to 22 to 25°C, perfusion ; flow is reduced to 1-8 to 1-2 1/min per M2. Short _ periods with an even lower flow or circulatory arrest have been used. The intraventricular anatomy is assessed through the right atrium and tricuspid valve to evaluate the feasibility of performing the Rastelli procedure. The ventricular septal defect must be adequate in diameter to allow a completely unobstructed outflow from the left ventricle; this may involve enlarge- ment. The position of the aorta and the tricuspid valve with its subvalvar apparatus must permit placement of the patch to redirect the left ventri- cular outflow into the aortic root. Visualisation of the papillary muscles and chordae of the tricuspid valve helps to select the optimal ventriculotomy site. The ventriculotomy is an oblique or vertical incision directed towards the main pulmonary artery. Care must be taken to avoid damage to major branches of the coronary arteries. In the first patients in this series, Rastelli's Fig. 3 Left ventricular flow is diverted to the aorta through the ventricular septal defect using a large patch. Ao, aorta. original description was followed, that is with a http://heart.bmj.com/ conduit lying to the right of the aorta. Since 1973 we have directed the ventriculotomy incision and the conduit to the left of the aorta whenever the main pulmonary artery is to the left of or behind the aorta. In this position, the conduit does not cross the midline, and compression by the sternum is avoided. We do not resect a button of myocardium, though very hypertrophied right ven- on September 27, 2021 by guest. Protected copyright. tricular musculature at the edge of the ventriculo- tomy is often resected. The ventricular septal defect is again inspected via the ventriculotomy. If its diameter is smaller than the aortic valve annulus, it is enlarged by - incision or resection of the septum towards the lateral-superior aspect of the defect (Fig. 2). If accessible, the leaflets of the pulmonary valve are oversewn through the ventricular septal defect, though this may also be done later via the pulmonary artery.