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UPMC Children’s Heart Institute CT Surgery Team Outlines Optimal Surgical Selection Process for Patients with Transposition of the Great Arteries Complicated by LVOTO

July 5, 2024

Researchers from the Heart Institute at UPMC Children's Hospital of Pittsburgh recently published a study in the Annals of Thoracic Surgery detailing their selection process for the Rastelli and Nikaidoh operations in treating patients with transposition of the great arteries (TGA) complicated by a left ventricular outflow tract obstruction (LVOTO).

The study, conducted by the pediatric cardiothoracic surgery team at UPMC Children’s, was led by first author Laura Seese, MD, MS. Victor O. Morell, MD, chief of pediatric cardiothoracic surgery at UPMC Children’s and internationally recognized expert in complex transposition was the study’s senior author.

The team’s study provides details and clinical insights into the pathoanatomic criteria influencing surgical decisions and their impact on clinical outcomes in patients with complex transposition.

About the Study and Its Findings

This study evaluated pediatric patients who underwent either the Nikaidoh or Rastelli operation for three main groups of patients with complex transposition: TGA with LVOTO, congenitally corrected TGA (cc-TGA) with LVOTO, or double-outlet right ventricle TGA type (DORV) with LVOTO from June 2004 to June 2021. The study was designed to evaluate the impact of the algorithm that guides surgical decision making in these complex patients at UPMC Children’s. This algorithm includes patient-specific anatomic factors that guide surgical selection to optimize early postoperative and long-term outcomes.   

The study confirmed that patients may be better suited to undergo a Nikaidoh operation if they had a pulmonary annulus greater than 5 mm, anteriorly/posteriorly oriented great vessels, remote or restrictive ventricular septal defects, anomalous coronary anatomy crossing the right ventricular outflow tract or right ventricular hypoplasia. On the other hand, the Rastelli operation was preferred for patients with side-by-side great vessels and central, nonrestrictive ventricular septal defects.

Utilizing this approach that allows the patient’s anatomy to drive surgical decision making, impressively mitigated the surgical risk of both procedures, evidenced by the fact that both groups had similar incidences of postoperative complications and mortality. The rates of reoperation were comparable between the two, with the Rastelli group primarily requiring conduit replacements and the Nikaidoh group needing valvular repairs or replacements. Echocardiographic outcomes at a median follow-up of one month and five years showed that patients in both groups had favorable outcomes, with the Nikaidoh patients showing some expected pulmonary insufficiency due to the nature of the procedure.

Implications for Clinical Practice

The findings from the study show the importance of pathoanatomic criteria in the surgical selection process for patients with complex transposition. With careful evaluation of the patient’s anatomic features, pediatric heart surgeons can choose the procedure best suited to each individual’s unique anatomy, potentially improving upon long-term clinical outcomes while minimizing possible postsurgical complications.

Read more about the study’s findings using the reference link below.


Seese L, Diaz Castrillon C, Da Fonseca Da Silva L, Tarun S, Castro-Medina M, Viegas M, Da Silva JP, Morell VO. Optimizing surgical selection for transposition with left ventricular outflow tract obstruction. Ann Thorac Surg. 2024; 117: 370-378.