Long-term outcomes of the Rastelli operation in conotruncal defects: a 30-year single-center experience

Abstract

Background
Numerous surgical strategies currently exist for managing D-transposition of the great arteries (D-TGA) with ventricular septal defect (VSD) and pulmonary stenosis (PS). This study evaluates survival, freedom from reintervention, and procedural effectiveness over a 30-year institutional experience (1988–2018). A retrospective analysis was conducted on all 64 patients who underwent the Rastelli procedure at Prince Sultan Cardiac Centre, Riyadh, Saudi Arabia. Freedom from reintervention and survival were assessed using Kaplan–Meier curves with numbers at risk reported at each landmark, and groups were compared with the log-rank test and Cox proportional-hazards models.


Results
A Blalock–Taussig shunt was placed in 52 patients (53.1% of all previous-procedure events), and balloon atrial septostomy was performed in 12 patients (18.8%). After the index Rastelli operation, 37 patients (57.8%) remained free from any reintervention; 21 (32.8%) underwent surgical right ventricle-pulmonary artery (RV-PA) conduit replacement or pulmonary valve replacement (PVR); 12 (18.8%) underwent any catheter-based right ventricular outflow tract/ pulmonary artery (RVOT/PA) intervention; and 6 patients (9.4%) had a catheter-based procedure as their only reintervention. Kaplan–Meier freedom from surgical reintervention was 100% at 1 year, 91.3% at 5 years, 77.4% at 10 years, 53.9% at 15 years, and 49.8% at 20 years (median 16 years). Overall survival was 98.4% at 1 year and 95.2% from year 5 onward (3 deaths total: 1 in-hospital, 2 late, all within 3.5 years of surgery; 95% CI 85.9–98.4%). No patient required reoperation for left ventricular outflow tract obstruction (LVOTO) over the entire follow-up period.


Conclusions
The Rastelli procedure for D-TGA, VSD, and PS offers excellent early, mid- and long-term survival. Reintervention is primarily driven by RV-PA conduit replacement. Aggressive resection of the conal septum, with or without formal VSD enlargement, appears to prevent late LVOTO.