Rastelli procedure

The Rastelli procedure is a surgery used to correct certain combinations of cardiovascular defects in patients with cyanotic congenital heart disease.

Rationale

The operation is based on a re-direction of ventricular outflows using an intracardiac baffle that tunnels the left ventricle to the aorta and an external valved conduit that connects the right ventricle and the pulmonary artery ^1-4.    

Most frequent indications include:

• dextro-transposition of the great arteries (d-TGA) associated with ventricular septal defect (VSD) and some degree of left ventricular outflow tract (LVOT) obstruction
• cardiac lesions characterized by two ventricles and an overriding aorta with pulmonary outflow tract obstruction:
  • pulmonary atresia with VSD (PA-VSD)
  • double outlet right ventricle with pulmonary stenosis or atresia

Procedure

A patch (Gore-Tex) is used to direct oxygenated blood from the left ventricle to the aorta. The patch also closes the VSD.  The pulmonary valve is surgically closed and an artificial conduit and valve are constructed from the right ventricle to the pulmonary bifurcations, allowing deoxygenated blood to travel to the lungs for reoxygenation ^1-4.

Complications, treatment and prognosis

Complications of the Rastelli procedure include ³:

• extra-cardiac conduit stenosis (with or without regurgitation), calcification, kinking and aneurysm
• tunnel patch from the left ventricle to the aortic valve may be complicated by leakage, obstruction, stenosis, or aneurysm
• branch pulmonary artery stenosis
• biventricular dysfunction

While the early surgical mortality of the Rastelli is acceptable at approximately 5%, questions have been raised about long-term results ⁵. LVOT and right-sided conduit obstruction can require percutaneous intervention with stent placement or repeat surgery. Nearly 50% of patients who underwent the Rastelli procedure either needed cardiac transplantation or died 20 years after the procedure ^2,5.

History and etymology

The procedure was conceived by Gian Carlo Rastelli as a surgical repair for children born with TGA), VSD, and pulmonary stenosis ¹. It was first successfully performed by Dr. Robert Wallace at the Mayo Clinic on July 26, 1968 ^1,6.