Surgery for malposition of the great arteries: the REV procedure

The REV procedure was introduced in 1980 to treat transposition of the great arteries with ventricular septal defect (VSD) and pulmonary stenosis and malpositions similar to transposition of the great arteries (TGA). It aims at overcoming the drawbacks and limitations of the classic Rastelli operation, such as subaortic stenosis, late ventricular deterioration, arrhythmias and sudden death. In particular, the resection of the infundibular septum allows for the placement of a straighter, smaller ventricular patch, bulging much less in the right ventricular cavity. The extensive mobilization of the main pulmonary branches permits a direct connection with the right ventricular incision, thus avoiding the need for an extracardiac conduit. The procedure was performed in 205 patients as of December 2003 with 12% hospital mortality. Patients for whom the Rastelli operation would have been contraindicated, were accepted for REV repair. Late results show a clear improvement over those reported with the Rastelli operation in terms of overall survival (85% at 25-year follow-up interval) and prevalence of reoperation for right ventricular obstruction. Obstruction of the left ventricle-to-aorta tunnel is exceedingly rare. This operation should be considered the gold standard when new surgical options are considered for this complex form of transpositions/malpositions of the great arteries.