Long-term Effect of Enlargement of a Ventricular Septal Defect in the Rastelli Procedure

We investigated the effect of ventricular septal defect (VSD) enlargement on long-term surgical results, late arrhythmia, and left ventricular (LV) function in the Rastelli procedure for D-transposition of the great arteries with LV outflow tract obstruction (LVOTO). From 1979 to 2001, 74 patients (D-transposition of the great arteries, n = 56; double outlet right ventricle, n = 18) underwent the Rastelli procedure. In group A, 46 patients underwent the Rastelli procedure with VSD enlargement, and in group B, 28 patients underwent the Rastelli procedure without enlargement. There were no hospital deaths. Actuarial survival at 20 years was 80% in group A and 91% in group B ( P  = 0.50). Freedom from reoperations at 20 years was 40.1% in group A and 52.0% in group B. Reoperations for LVOTO were performed in 2 patients in both groups. In postoperative catheterization, LV ejection fraction in group A was 57.1% ± 8.7% vs 57.2% ± 8.1% in group B ( P  = 0.97); LV end-diastolic volume, 150.0% ± 47.2% vs 142.0% ± 36.9% of the normal volume ( P  = 0.97). In long-term postoperative echocardiography, the pressure gradient of the LV to the aorta was 12.0 ± 12.8 vs 17.7 ± 26.0 mm Hg in groups A and B ( P  = 0.31). There were no differences between the groups regarding basal rhythms, anti-arrhythmic agents, and pacemaker implantation rate. VSD enlargement in the Rastelli procedure can be safely performed without early mortality and with long-term low mortality and morbidity regarding arrhythmia, LV function, and reoperation for late LVOTO. VSD enlargement should be considered as an option for avoiding long-term LVOTO.