Invited Commentary

Surgical management of d-TGA, ventricular septal defect (VSD), and left ventricular outflow tract obstruction (LVOTO) continues to be controversial. In these patients, symptoms are mostly related to the degree of LVOTO and the consequent decrease in pulmonary blood flow. Treatment of symptomatic infants varies from systemic artery to pulmonary artery shunts (usually with a surgical atrial septectomy) in preparation for a future Rastelli operation, to resection of the LVOTO whenever anatomically feasible, accompanied by closure of VSD and a Mustard or Senning operation. Dr. Oelert and his colleagues must be congratulated for their impressive results with a group of patients with such complex pathology. Unfortunately the authors do not include a detailed description of the nature of the LVOTO. In our experience, isolated and short segmented forms of fibromuscular type obstructions, aneurysms of the pars membranacea septi and localized excrecences of remnants of endocardial cushion tissue lend themselves readily to excision through the pulmonary artery and valve. Obstruction due to a long segment, tunnel-type fibromuscular obstruction is much more difficult to treat and at times impossible, given the nature of the lesion. Ideally, the extent and the anatomic type of subpulmonary stenosis should be recognized preoperatively by cineangiography and echocardiography. Because of the excellent early and late results with the Rastelli operation we favor in this particular subset of patients (with long segment obstruction), a palliative shunt rather than attempted resection followed later by a Rastelli operation.