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Papers by Zohair Halees

McGill Journal of Medicine, 2020

World journal for pediatric & congenital heart surgery, Jul 1, 2018

The World Society for Pediatric and Congenital Heart Surgery (WSPCHS) is the largest professional... more The World Society for Pediatric and Congenital Heart Surgery (WSPCHS) is the largest professional organization in the world dedicated to pediatric and congenital heart surgery. The purpose of this article is to document the first decade of the history of WSPCHS from its formation in 2006, to summarize the current status of WSPCHS, and to consider the future of WSPCHS. The WSPCHS was incorporated in Canada on April 7, 2011, with a head office in Montreal, Canada. The vision of the WSPCHS is that every child born anywhere in the world with a congenital heart defect should have access to appropriate medical and surgical care. The mission of the WSPCHS is to promote the highest quality comprehensive cardiac care to all patients with congenital heart disease, from the fetus to the adult, regardless of the patient's economic means, with an emphasis on excellence in teaching, research, and community service.

Catheterization and Cardiovascular Diagnosis, 1996

Our objective was to assess the immediate and short-term results of stent implantation to relieve... more Our objective was to assess the immediate and short-term results of stent implantation to relieve pulmonary artery stenosis (PAS). Thirty-seven patients underwent an attempt at stent implantatlon at a medlan age of 7.0 years (range, 0.G31.4 years) and a median weight of 20.5 kg (range, 7.4-85 kg). Twenty-two patients had previous tetralogy of Fallot repair. A total of 55 stents were Implanted successfully in 36 patlents. The peak systolic gradient across the stenotic segment decreased from a mean of 43 2 20.4 mmHg prestent to 13 f 13.9 mmHg (P a:: 0.001) poststent. The diameter of the narrowest segment Increased from a mean of 4.8 f 1.6 mm to 10.5 f 2.6 mm (P ,:I 0,001). The right ventrlcular-to-aortic mean systolic pressure ratio decreased from 0.74 2 0.2 to 0.52 ? 0.1 9 (P c: 0.001). Complications included balloon rupture prior to full stent expansion in 4 patients (in 2 patients the stent was positioned in the superior vena cava, and in 2 in the inferior vena cava), distal migration of a stent which was successfully retrieved at surgery 1 mo later in 1 patient, and tethering of the stent to the balloon requiring surgical removal in 1 patient. One patient died several hours after stent placement. Sixteen patients underwent repeat catheterization at a mean follow-up interval 010.9 * 0.5years (range, 0.2-2.0years). The mean gradient across the stent for these 16 patients was 26.7 f 19.8 mmHg, and there was no change in the mean diameter (9.4 2 3.2 mm). Two patients developed stenosis related to neointimal proliferation at the stent site which was redilated successfully. In conclusion, stent irnplantation is generally safe and effective in relleving PAS.

The Journal of Thoracic and Cardiovascular Surgery, 1997

The Journal of Thoracic and Cardiovascular Surgery, 1995

Journal of the American College of Cardiology, 2003

prior to Amplatzer device implantation. 3D was performed with transthoracic rotational acquisitio... more prior to Amplatzer device implantation. 3D was performed with transthoracic rotational acquisition at 3' intervals (TomTec Echoscan 3.0). Diameters of defect, predicted mean diameter and drea were measured by TEE and 3D. Results were compared to stretched balloon diameter and final Amplatzer waist diameter. All patients underwent successful implantation procedure wthout residual leaks after 6 months. Results. Quality of 3D was good in 11 pts and satisfactory in 7. Mean stretched/ Amplatzer diameter was 20r5/22+5mm and stretched/Amplatzer waist area 3.2t1.61 3.9k2.0 cm2. Maximal diameters were severely underestimated by TEE and not by 3D: 14*4 vs 23*5 mm (p<O.OOl), with calculated areas of 1.2i0.6 vs 2.9+1.5cm2 resp. (p<O.OOl). 30 had good correlation and close agreement to stretch diameter (r=0,87) with small underestimation (3mm) of true size of implanted device. TEE underestimated defect size markedly by >6mm (r=0,59). 1168-155 Systemic Dissemination of Nickel in Patients With Atrial Conclusions. Transthoracic 3D, as opposed to TEE, allows accurate transthoracic mea-Septal Defects Following the Implantation of the surements of ASD diameter and reliable prediction of Amplatzer size in young patients.

Journal of the American College of Cardiology, 1997

Objectives. We attempted to evaluate the role of balloon angioplasty in the treatment of discrete... more Objectives. We attempted to evaluate the role of balloon angioplasty in the treatment of discrete coarctation of the aorta in adolescents and adults, with special emphasis on long-term results. Background. Controversy persists over the use of balloon dilation for the treatment of native coarctation of the aorta. Methods. Between July 1986 and January 1997, 43 consecutive adolescent and adult patients with discrete coarctation of the aorta underwent balloon angioplasty. One-to 10-year follow-up data of 37 patients, including results of cardiac catheterization and magnetic resonance imaging (MRI), form the basis of this study. Results. No early or late deaths occurred. Balloon angioplasty produced a reduction in the peak to peak coarctation gradient from a mean ؎ SD of 69 ؎ 24 mm Hg (95% confidence interval [CI] 61 to 76) to 12 ؎ 8 mm Hg (95% CI 10 to 14.8) (p < 0.001). Follow-up catheterization 12 months later (37 patients) revealed a residual gradient of 6.7 ؎ 6 mm Hg (95% CI 4.6 to 8.9); 3 (7%) of 43 patients had suboptimal results with development of recoarctation, defined as peak gradient >20 mm Hg, with successful repeat angioplasty. A small aneurysm developed at the site of dilation in 3 (7%) of the 43 patients. MRI follow-up data 1 to 10.8 years (mean 5.2 ؎ 2.7) after angioplasty (37 patients) revealed no new aneurysm or appreciable change in the size of the preexisting aneurysm in the three patients. The blood pressure had normalized without medication in 27 (73%) of 37 patients at follow-up examination. Conclusions. Balloon angioplasty is safe and effective and should be considered a viable alternative to operation for treatment of discrete coarctation of the aorta in adolescents and adults.

Journal of Interventional Cardiology, 1998

... VASUDEVAN SIVANANDAM, MRCP, FACA,* MOHAMMED EID FAWZY, FRCP, FACC,* LAYTH A. MIMISH, FRCP, FA... more ... VASUDEVAN SIVANANDAM, MRCP, FACA,* MOHAMMED EID FAWZY, FRCP, FACC,* LAYTH A. MIMISH, FRCP, FACC,&amp;amp;amp;amp;quot; KUSHROW NIAZI, FRCP, FACC,&amp;amp;amp;amp;quot; ABDUL HALIM ... Mitral balloon valvo-tomy in children with Inoue technique: Immediate and inter-mediate term results. ...

Journal of Cardiothoracic and Vascular Anesthesia, 2002

THE ANESTHESIA-RELATED deaths of 2 patients with Williams syndrome and supravalvular aortic steno... more THE ANESTHESIA-RELATED deaths of 2 patients with Williams syndrome and supravalvular aortic stenosis (SVAS) are reported. There are 3 reports in the anesthesia literature of favorable outcomes of anesthetic management of patients with Williams syndrome.1-3 Other reports in the pediatric literature documented severe coronary artery disease, myocardial infarction,4,5 and anesthesia-related cardiac arrest and mortality6,7 in children with Williams syndrome. A review of the surgical literature described a significant incidence of coronary artery involvement in patients with SVAS.8 None of these reports described the anesthetic management of these patients. This case report highlights the potential risks of providing sedation or general anesthesia for patients with Williams syndrome, SVAS, and coronary artery disease.

Journal of Cardiac Surgery, 2010

We report results of left atrioventricular valve reoperations (LAVVR) following atrioventricular ... more We report results of left atrioventricular valve reoperations (LAVVR) following atrioventricular septal defect (AVSD) repair and examine variables predictive of outcome. Multiple demographics and operative variables were analyzed to determine factors affecting survival and reoperation. Forty patients following partial (n = 9) or complete (n = 31) AVSD repair underwent 47 LAVVR (1992-2005). Median age was 0.87 years (24 days-7.7 years) at initial AVSD repair and 3.15 years (84 days-13.6 years) at subsequent LAVVR with median interval between AVSD repair and LAVVR of 1.76 years (1 day-12.9 years). First LAVVR included repair (n = 20) or replacement (n = 20). Operative mortality was 10% and five-year survival was 76 +/- 6%. Significant risk factors were complete AVSD (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001), valve replacement (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.001) for early death, and young age at time of LAVVR (p = 0.03) for late death. Five-year freedom from LAVV re-intervention was 100% for replacement versus 55 +/- 13% for repair (p = 0.006). Overall, ejection fraction increased to 61 +/- 3% versus 42 +/- 2% preoperatively (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01), and left-ventricle end-diastolic dimension Z-score decreased to 0.05 +/- 0.36 versus 3.1 +/- 0.3 preoperatively (p &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;lt; 0.01). Eighty-seven percent of children were in New York Heart Association class I/II at latest follow-up. LAVVR results in significant clinical improvement and lasting recovery in ventricular chamber function and size. Valve repair offers survival advantage and should be aggressively attempted; however, it is only achievable in 50% of cases. Valve replacement is necessary in cases associated with complex LAVV morphology or following repair failure. At intermediate follow-up, patients continue to be at risk of major valve-related morbidity, requirement for re-intervention, and cardiac death.

The International Journal of Biostatistics, 2010

Family studies are widely used for research into genetic and environmental influences on human tr... more Family studies are widely used for research into genetic and environmental influences on human traits. In this paper, we establish statistical methodology for the estimation of a new measure of sib similarity with respect to dichotomous traits measured on each member of within family sib-pair. We call this parameter "excess risk." For inference problems involving a single sample, we construct a large sample confidence interval on the concerned parameter. It has long been suspected that consanguinity is a risk factor for many genetic defects. Therefore, we establish a procedure to test the significance of the difference between excess risk parameters in a sample of consanguineous marriages and another sample of non-consanguineous marriages. We apply the methodology to data from a hospital-based congenital heart defects registry in Saudi Arabia, a population in which consanguinity is quite common.

European Journal of Cardio-Thoracic Surgery, 2005

Objective: There is lack of information regarding the long-term behavior of aortic valve reconstr... more Objective: There is lack of information regarding the long-term behavior of aortic valve reconstruction with pericardium (AoR). A 16-year follow-up is reported here. Methods: Between 1988 and 1995, 92 consecutive patients had AoR with bovine (Group I, nZ27) or glutaraldehydetreated autologous pericardium (Group II, nZ65). The mean age was 30 years (range 12-68). There were 65% males, 92% in sinus rhythm, 84% had rheumatic etiology and 36% had 'other valve' surgery. Mitral valve replacement with a mechanical prosthesis is a contraindication to the operation. Results: Hospital mortality was 2%. The reconstructed aortic valve performed well with excellent hemodynamics. The mean followup interval was 10.5G4 years, range 9-16 years (longer for group I,12 versus 10 years) with 4% late deaths and seven patients lost to follow-up. Survival rate was 85G4%. There were no episodes of thromboembolism. Freedom from reoperation for the whole group was 68G5% at 10 years and 47G6% at 16 years. For group I, it was 68G9% at 10 years and 48G10% at 16 years, while for group II it was 72G6 and 45G8% at 10 and 15 years, respectively. Excluding endocarditis (one in group I and seven in group II) and 'other' reasons for reoperation (two in group I and three in group II), the freedom from structural valve degeneration (SVD) at 10 and 16 years was 78G1 and 55G10% for group I. For group II, it was 80G5% at 10 years and 58G9% at 15 years. The mean interval at which the valve degenerated was 8.8 yearsG3.6 and did not differ between the two groups. Conclusions: AoR is feasible with good hemodynamics, low mortality and thromboembolic rate. Its behavior at 10 years is comparable to that of stentless aortic valve bioprosthesis. It can be performed with either xenopericardium or glutaraldehyde-treated autologous pericardium, but the latter has the advantage of being inexpensive and readily available.

European Journal of Cardio-Thoracic Surgery, 2012

OBJECTIVES: The Ross procedure is the preferred aortic valve replacement (AVR) choice in small ch... more OBJECTIVES: The Ross procedure is the preferred aortic valve replacement (AVR) choice in small children. Nonetheless, it is a complicated surgery and there are concerns that subsequent cardiac reoperations are exceptionally complex and associated with high morbidity and mortality. We examine the surgical spectrum and report outcomes of cardiac reoperations in patients who had undergone the Ross procedure during childhood. METHODS: Records of 227 consecutive children (<18 years old) who had undergone the Ross procedure at our institution from 1991 to 2004 were reviewed. Our patient cohort was 50 patients who underwent 58 cardiac reoperations following the Ross procedure during the follow-up. Time-related outcomes were analyzed. RESULTS: From 1992 to 2009, 50 patients, 37 males (74%), underwent cardiac reoperation at a mean age of 15.6 ± 5.2 years and a mean interval of 3.9 ± 3.0 years following the Ross procedure. Risk factors for cardiac reoperation following the Ross procedure on multivariable analysis were rheumatic fever, aortic regurgitation, concomitant cardiac surgery, use of fresh homografts and earlier era of surgery. Overall, 32 (55%) reoperations were isolated procedures whereas 26 (45%) were more complex involving 2-4 simultaneous cardiac procedures. In total, 92 procedures were performed including AVR (n = 31), homograft replacement (n = 23), mitral valve replacement (n = 18), mitral valve repair (n = 11), tricuspid valve repair (n = 5) and other (n = 4). There was no operative mortality and one late death. Survival was 98% at 10 years. During the follow-up, 8 of 50 patients required further cardiac surgery following initial reoperation with freedom from additional cardiac surgery of 82% at 10 years. Subsequent cardiac surgery risk was higher in patients with pre-operative aortic regurgitation and those who had concomitant surgery at time of Ross on log-rank analysis. Among survivors, 96% are in New York Heart Association class I/II. CONCLUSIONS: A wide range of cardiac reoperations may be required in children following the Ross procedure, especially those with underlying rheumatic aetiology, aortic regurgitation and multivalvular involvement. Despite complexity, reoperation following the Ross procedure can be performed with low mortality and good mid-term results. This information should be taken into consideration during the selection of aortic valve substitute in children.

European Journal of Cardio-Thoracic Surgery, 2013

OBJECTIVES: Children with various single ventricle anomalies are at risk of developing systemic v... more OBJECTIVES: Children with various single ventricle anomalies are at risk of developing systemic ventricular outflow tract obstruction (SVOTO) following volume unloading with cavopulmonary connection (CPC). We aim to evaluate the value of Damus-Kaye-Stansel (DKS) anastomosis at the time of CPC in eliminating late SVOTO risk. METHODS: Retrospective review of single ventricle patients who underwent DKS concurrent with CPC between 1997 and 2012 was performed. Clinical, echocardiographic and angiographic outcomes were analysed. RESULTS: Thirty-six children with single ventricle underwent DKS at the time of Glenn bidirectional CPC (n = 29) or Fontan total CPC (n = 7). The underlying anatomy was double inlet left ventricle (n = 18), double outlet right ventricle (n = 8), unbalanced atrioventricular septal defect (n = 4) and other (n = 6). Prior palliation included pulmonary artery band (n = 35), coarctation/arch repair (n = 11) and atrial septectomy (n = 8). Median age at the time of DKS was 8.9 months (range 3.6 months-9.1 years) and the median weight was 6.7 kg (range 5-27 kg). At the time of DKS, 17 patients (47%) had no SVOT gradient and 19 (53%) had SVOT gradient (mean 23.4 ± 18.7 mmHg). Overall survival was 89 and 83% at 1 month and 5 years, respectively. None of the deaths were related to SVOTO or DKS complications. When present, SVOT gradient decreased from 23.4 ± 18.7 mmHg preoperatively to 0 after DKS (P < 0.001). At the last follow-up, none of the patients developed any SVOT gradient; 78% of them had zero or trivial aortic/neoaortic valve regurgitation while 22% had mild regurgitation. None of the patients had evidence of compression of the left pulmonary artery or bronchus. Eighty-one percent of patients have reached or are suitable candidates awaiting final palliative surgery. CONCLUSIONS: DKS can be safely performed in conjunction with CPC without added mortality risk. It is very effective in mitigating SVOTO risk, with sustainable good semilunar valves function. Our data support an aggressive approach to performing DKS concurrent with CPC in children with single ventricle pathologies at risk of developing SVOTO.

Critical Care, 1998

Background: Whole body hyperthermia induced by radiative systems has been used in therapy of mali... more Background: Whole body hyperthermia induced by radiative systems has been used in therapy of malignant diseases for more than ten years. Von Ardenne and co-workers have developed the 'systemiche Krebs-Mehrschritt-Therapic' (sKMT), a combined regime including whole body hyperthermia of 42°C, induced hyperglycaemia and relative hyperoxaemia with additional application of chemotherapy. This concept has been employed in a phase I/II clinical study for patients with metastatic colorectal carcinoma at the Virchow-Klinikum since January 1997. Methods: The sKMT concept was performed eleven times under intravenous general anaesthesia, avoiding volatile anaesthetics. Core temperatures of up to 42°C were reached stepwise by warming with infrared-A-radiation (IRATHERM 2000®). During the whole procedure blood glucose levels of 380-450 mg/dl were maintained as well as PaO 2 levels above 200 mmHg. Extensive invasive monitoring was performed in all patients including measurements with the REF-Ox-Pulmonary artery catheter with continuous measuring of mixed venous saturation (Baxter Explorer®) and invasive monitoring of arterial blood pressure. Data for calculation of hemodynamic and gas exchange parameters were collected four times, at temperatures of 37°C, 40°C, 41.8-42°C and 39°C, during measurements FiO 2 was 1.0 at all times. Fluids were given in order to keep central-venous and Wedge pressure within normal range during the whole procedure. Statistics were performed using the Wilcoxon Test. Results: Statistically significant differences were found between heart rate, cardiac index and systemic vascular resistance comparing data at 37°C and 42°C. Heart rate and cardiac index increased to a maximum at 42°C (P < 0.0001) whereas systemic vascular resistance had its minimum at 42°C (P < 0.0001). Mean arterial pressure dropped with increasing temperature, differences were not significant. Calculation of stroke volume index and ventricular volumes showed only a slight decrease in endsystolic volumes with increasing temperature, the resulting differences in right ventricular ejection fraction were marginally significant (P = 0.038) comparing 42°C to baseline. Right ventricular stroke work index as well as mean pulmonary arterial pressure increased at 42°C (P = 0.0115 and P = 0.0037), pulmonary vascular resistance only dropped little compared to systemic vascular resistance, left ventricular stroke work index even dropped with increasing temperature, though showing no significant difference. Values for mixed venous oxygen saturation did not vary during therapy, pulmonary right-left shunt showed a temperature associated increase (P = 0.0323) to a maximum at 42°C. Conclusion: Under the procedure of sKMT cardiac function in patients, who do not have any pre-existing cardiac impairment, can be maintained almost unchanged, ie with normal right and left ventricular pressure, despite an increase in right ventricular stroke work Acknowledegment: Supported by Deutsche Krebshilfe.

Cardiology in the Young, 2000

We describe what is, to the best of our knowledge, a previously unreported association in patient... more We describe what is, to the best of our knowledge, a previously unreported association in patients with similar facial features, skin and joint laxity, of lengthening and tortuosity of systemic, pulmonary and coronary vessels. We evaluated 12 patients with similar phenotypes, from eight different families. Detailed echocardiographic and angiographic evaluations were performed in all, and biopsies of the skin in seven. All patients have elongated facies, prominent ears, micrognathia and laxity of their joints. Angiographic pictures showed a varying degree of lengthening and tortuosity of systemic, pulmonary, and coronary arteries. Pulsatile carotid arteries formed cervical masses in 2 patients, and three had severe renal arterial stenoses. All showed varying degrees of branch and peripheral pulmonary arterial stenosis, necessitating placement of stents in six. Biopsy of the skin proved normal in all seven patients studied, thus excluding cutis laxa, Ehlers-Danlos and Marfan syndromes...

Cardiology in the Young, 1993

SummaryA seven-month-old boy with severe respiratory distress because of absence of the leaflets ... more SummaryA seven-month-old boy with severe respiratory distress because of absence of the leaflets of the pulmonary valve underwent banding of the pulmonary trunk. Postoperative recovery was uneventful with dramatic improvement of his general and hemodynamic status. Repair was performed successfully almost two years later when the child had grown satisfactorily and was in stable condition.

The Annals of Thoracic Surgery, 2008

Background. Optimal repair of anomalous origin of left coronary artery from pulmonary artery (ALC... more Background. Optimal repair of anomalous origin of left coronary artery from pulmonary artery (ALCAPA) relies on the creation of a dual-coronary system. If the anomalous coronary arises at a long distance from the aorta, we use various coronary extension techniques to facilitate tension-free implantation. Methods. Thirty patients underwent ALCAPA operations using direct coronary transfer (n ‫؍‬ 11) or coronary extension techniques (n ‫؍‬ 19). Surgical outcomes were analyzed. Results. Median age and weight were 5.7 months (range, 46 days to 5.45 years) and 5.35 kg (range, 3.3 to 15.9 kg). Five patients had concomitant mitral annuloplasty. Mean cardiopulmonary bypass and ischemic times were 108 ؎ 38 and 57 ؎ 25 minutes. Two patients required intraoperative revision of the implantation. There were three hospital deaths (10%) and no late deaths. Follow-up echocardiograms demonstrated significant improvement postoperatively vs preoperatively in shortening fraction (35% ؎ 2% vs 16% ؎ 2%, p < 0.00001), ejection fraction (64% ؎ 3% vs 32% ؎ 4%, p < 0.00001), and mitral regurgitation (11% moderate vs 70% moderate or severe, p ‫؍‬ 0.0002). Left ventricular end-diastolic dimension Z-score decreased from 9.1 ؎ 0.9 to 1.2 ؎ 0.5 (p < 0.00001). Both techniques were equally effective. Two patients underwent reoperation 1 and 12 years postoperatively (coronary artery bypass grafting, 1; mitral repair with coronary angioplasty, 1). Surviving patients remain asymptomatic (p < 0.00001). Conclusions. Dual-coronary system can be established in patients with ALCAPA. Coronary extension implantation techniques have acceptable operative mortality and excellent cardiac recovery and late survival. Although the rate of late coronary occlusion is low, continual ventricular or mitral dysfunction should trigger evaluation of persistent coronary compromise.

The Annals of Thoracic Surgery, 1997

Background. The role of surgery in managing patent ductus arteriosus (PDA) was studied in the era... more Background. The role of surgery in managing patent ductus arteriosus (PDA) was studied in the era of the Rashkind double-umbrella device. Methods. All 354 patients with PDA referred to our center in a 5-year period were included in this report. Of the 354 patients, 236 underwent cardiac catheterization with the intent of transcatheter PDA closure, and 118 had surgical intervention. Results. In 46 (19.5%) of the 236 patients having cardiac catheterization, the procedure either was abandoned or failed. Color Doppler echocardiography demonstrated total occlusion of the ductus after 24 hours in 97 patients (41%) in the cardiac catheterization group. An additional 20 patients had no residual leaks at follow-up. Twenty other patients underwent reocclusion because of a residual shunt. Thus, of the 236 patients, 137 (58%) had successful complete closure of the PDA. Surgical PDA ligation was performed in 118 patients as the initial procedure and in 26 of the 46 patients in whom transcatheter closure was abandoned. If the remaining 20 patients in whom transcatheter closure failed are added to the 144 patients who underwent PDA ligation, the percentage having surgical intervention versus transcatheter occlusion is higher than 46%. Conclusions. Our data suggest that surgery plays a major role in the management of patients with PDA despite the advent of new interventional catheterization techniques.

The Annals of Thoracic Surgery, 2009

Background. The Rastelli procedure is the standard surgical treatment of d-transposition of great... more Background. The Rastelli procedure is the standard surgical treatment of d-transposition of great arteries (d-TGA), ventricular septal defect (VSD), and pulmonary stenosis. Late morbidity is significant due to recurrent left ventricular outflow obstruction (LVOTO), early conduit obstruction, and arrhythmias, with troublesome late mortality. To avoid recurrent LVOTO, we routinely enlarge the VSD and resect the infundibular septum before LV baffling to the aorta. We examined the efficacy of this approach in mitigating recurrent LVOTO risk. Methods. Late echocardiographic and time-related clinical results of patients undergoing the Rastelli procedure were examined. Demographics and operative variables affecting outcomes were analyzed. Results. The Rastelli cohort comprised 36 patients with d-TGA, VSD, and pulmonary stenosis. Median age at operation was 2.4 years (range, 0.3 to 8.3 years). Pulmonary stenosis was present in 31 and atresia in 5. Twenty-two patients had undergone a previous aortopulmonary shunt, and 6 had an atrial septectomy. No operative or late deaths occurred. Time-related freedom from permanent pacemaker implantation, recurrent LVOTO on echocardiogram, and conduit replacement at 10 years was 82%, 100%, and 49%, respectively. Systolic function was normal in all but 3 patients and 92% were in New York Heart Association functional class I and II. None of the patients had late arrhythmias or required heart transplantation. Conclusions. Early and midterm survival after the Rastelli procedure is satisfactory. Aggressive resection of the infundibular septum to enlarge the VSD has mitigated the risk of LVOTO recurrence. Late conduit obstruction remains an important source of morbidity and frequently requires reintervention.