Rastelli Procedure

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Pathophysiology

 

The Rastelli operation was initially used for the repair of d-Transposition of the great vessels with ventricular septal defect and pulmonary stenosis. It has subsequently been used for a variety of congenital heart defects characterized by two ventricles and overriding of the aorta with severe pulmonary stenosis or pulmonary atresia. Pulmonary atresia with ventricular septal defect, and double outlet right ventricle with pulmonary stenosis or atresia are anatomic subtypes also frequently submitted for the Rastelli procedure. Cyanosis is the prevailing preoperative pathophysiology.

Surgical technique

The Rastelli repair requires cardiopulmonary bypass and aortic cross-clamping. The ventricular septal defect is visualized through a right ventriculotomy. Obstructive right ventricular muscle is excised. A large intra-ventricular baffle is sutured into place, closing the ventricular septal defect and redirecting left ventricular outflow to the more anteriorly placed aortic valve. A valved homograft conduit is used to achieve right ventricular to pulmonary artery continuity. Transesophageal echocardiography is performed to help assess adequacy of repair. Cardiopulmonary bypass time and aortic cross-clamp time required to complete repair are usually moderate to long.

Postoperative considerations

The Rastelli operation, despite its many advantages, is an extensive operation that sometimes results in early hemodynamic instability. Invasive monitors used include arterial and central venous catheters. An LA line is used when needed for hemodynamic management. LA pressure acts as a surrogate for left ventricular end diastolic pressure, an excellent indicator of left ventricular performance. Non-invasive monitors include NIRS (near infrared spectroscopy) probes to assess adequacy of regional and global perfusion and traditional pulse oximetry. Vasoactive agents might include epinephrine and/or milrinone. Numerous other agents are available and are tailored to the specific needs of the patient, targeting adequate oxygen delivery to the tissues of the body and optimization of cardiac output. Satisfactory postoperative hemodynamics depend on free, unobstructed egress of blood from both the left ventricle and the right ventricle. Obstruction to either outflow tract will contribute to ventricular failure. Arrhythmia is a potential postoperative complication. Temporary atrioventricular pacing capability must be readily available. Bleeding is occasionally encountered following the Rastelli procedure. Intracardiac pressures should be normal postoperatively. Arterial oxygen saturation should be normal. Uncomplicated recovery from the Rastelli operation should result in a hospital stay of 1 to 2 weeks.