CPT® Code 33786

1. Indications

The Rastelli type operation is indicated for patients diagnosed with truncus arteriosus, a congenital cardiac anomaly that requires surgical intervention to correct the abnormal blood flow and structural defects of the heart. The following conditions warrant this procedure:

• Congenital Heart Defect: Truncus arteriosus is characterized by a single great vessel that arises from the heart, leading to mixed oxygenated and deoxygenated blood flow.
• Ventricular Septal Defect (VSD): The presence of a large VSD that necessitates closure to prevent complications such as heart failure or pulmonary hypertension.
• Obstructive Right Ventricular Muscle: The need to excise obstructive muscle tissue from the right ventricle to improve blood flow and function.

2. Procedure

The Rastelli type operation involves several critical procedural steps to effectively repair truncus arteriosus:

• Step 1: The procedure begins with access to the heart through a median sternotomy or thoracotomy, allowing the surgical team to reach the cardiac structures directly.
• Step 2: The thymus gland is resected to provide a clear surgical field and facilitate access to the heart.
• Step 3: The pericardium is incised, and a section is harvested for later use as a patch graft to aid in the closure of the VSD.
• Step 4: The single great vessel, or truncus, and its branches are carefully dissected free from surrounding tissues to prepare for reconstruction.
• Step 5: The aorta and superior and inferior vena cava are cannulated to establish cardiopulmonary bypass, which is essential for maintaining circulation during the operation.
• Step 6: The aorta is cross-clamped to control blood flow, allowing the surgical team to operate on the heart safely.
• Step 7: An incision is made in the right ventricle to visualize the VSD, and any obstructive muscle tissue is excised to improve right ventricular function.
• Step 8: The orifice of the pulmonary arteries is closed from within the heart without detaching the pulmonary artery, ensuring proper anatomical alignment.
• Step 9: An intra-ventricular baffle is constructed using the previously harvested pericardium or synthetic material, which is sutured into place to close the VSD and redirect blood flow to the aortic valve.
• Step 10: Continuity between the right ventricle and pulmonary artery is established using either an extra-cardiac, valved homograft conduit or a synthetic, nonvalved tube graft, depending on the specific needs of the patient.
• Step 11: If a valved homograft conduit is used, a tube graft extension may be required to bridge the distance between the ventriculotomy and the anastomosis site on the main pulmonary artery.
• Step 12: The valved conduit and/or tube graft is sutured to the right ventricle, ensuring careful placement to avoid damage to the papillary muscles.
• Step 13: The valved conduit is then sutured to the main pulmonary artery, completing the reconstruction of the outflow tract.
• Step 14: Finally, the sternum may be closed or left open for subsequent closure, and chest tubes are placed as needed to manage any postoperative fluid accumulation.

3. Post-Procedure

Post-procedure care following the Rastelli type operation involves monitoring the patient for any complications and ensuring proper recovery. Patients may require intensive care support initially, with close observation of vital signs and cardiac function. The placement of chest tubes will facilitate drainage of any excess fluid or air from the thoracic cavity. The surgical team will assess the patient's recovery progress, including the function of the newly established blood flow pathways. Follow-up imaging studies may be necessary to evaluate the success of the repair and the overall function of the heart. Depending on the patient's condition, the sternum may be closed during the initial surgery or in a subsequent procedure, which will also be monitored closely for any signs of infection or complications. Overall, the goal of post-procedure care is to ensure a smooth recovery and optimal cardiac function.