A Tribute to Giancarlo Rastelli

2005;79:1819-1823 Ann Thorac SurgAlexi-Meskishvili and Jia Li

Igor E. Konstantinov, Felice Rosapepe, Joseph A. Dearani, Vladimir V. A Tribute to Giancarlo Rastelli

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Tribute to Giancarlo Rastelligor E. Konstantinov, MD, PhD, Felice Rosapepe, MD, PhD, Joseph A. Dearani, MD,ladimir V. Alexi-Meskishvili, MD, PhD, and Jia Li, MD, PhD

ivision of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatric Cardiacurgery, Azienda Ospedaliera Monaldi, Napoli, Italy; Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota;

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iancarlo Rastelli (1933–1970) was a pioneer cardiacurgeon who developed a classification of atrioventricu-ar canal and a novel surgical procedure that revolution-zed the management of children with congenital heartisease. Rastelli lived a short, yet fascinating life. Hisork was ahead of its time and laid the foundation for

he treatment of complex congenital cardiac anomalies.(Ann Thorac Surg 2005;79:1819–23)

© 2005 by The Society of Thoracic Surgeons

iographical Notes

iancarlo Rastelli (1933–1970) was born on June 25,1933 in Pescara, Italy. His father, Vito Rastelli, was

journalist for a local newspaper. His mother, Luisaianchi, was an elementary school teacher. Rastelli had aounger sister Rosangela. She now lives in Milan, andome biographical information presented herein is basedn her personal account. In 1945, Rastelli’s family movedo Parma, the native town of both his parents. Hereastelli attended the Classic Lyceum of Romagna and

hen studied medicine at the University of Parma. Ras-elli was a hard-working student during his medicalchool years, but he had also developed a passion foroth classical music and mountain trekking (Fig 1A). Hepent much of his spare time either listening to hisollection of records or exploring mountain paths. As aedical student Rastelli completed his research projects

rst at the department of anatomy directed by Professoraetano Ottaviani from 1951 to 1953, and then at theepartment of general pathology directed by Professoromenico Rezzi from 1953 to 1955. During those yearsastelli developed a strong interest in the anatomy andathology of the heart. Rastelli graduated cum laude in957 and won “Le Petit” prize for the best graduationhesis entitled “Changes in the ATPase activity of the

yocardium during deep hypothermia.” In 1957, Rastelliegan his training in surgery at the department of sur-ery headed by Professor Antonio Bobbio at the Univer-ity of Parma Hospital. At that time, Rastelli’s particularnterest was in diagnostic techniques (Fig 1B).

Being a compassionate person, Rastelli always tried toxplain to his patient the exact underlying cause of thellness, as well as the anatomy, pathology, and treatmentptions. Yet Rastelli often did not have an answer for hisatients, nor did he have a surgical option to offer to his

ddress reprint requests to Dr Konstantinov, Division of Cardiovascular

burgery, Hospital for Sick Children, 555 University Ave, Toronto M5GX8, Ontario, Canada; e-mail: [email protected].

2005 by The Society of Thoracic Surgeonsublished by Elsevier Inc

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atients with congenital cardiac malformations. Thisuest for answers stimulated Rastelli, together with an-ther surgical trainee, Dr Carlo Battistini, to undertake

ntense surgical research. Drs Battistini, Bobbio, andastelli also shared a passion for classical music. Theypent hours together listening to classical music recordsnd discussing a variety of subjects. This friendship alsoacilitated successful research because they worked veryffectively as a team. This productive teamwork helpedastelli win a North Atlantic Treaty Organization

NATO) scholarship in 1960 that allowed him to continueis studies at the Mayo Clinic.Rastelli’s choice of the Mayo Clinic was inspired by the

ioneering work of John W. Kirklin (1917–2004), whoruly revolutionized heart surgery in the 1950s using the

ayo-Gibbon heart-lung machine. Doctor Kirklin be-ame professor and chairman of the department of sur-ery at the Mayo Clinic in 1960, and he held the latterosition until 1966 when he became chairman of theepartment of surgery at the University of Alabama.

nspired by the work of Kirklin, Rastelli (Fig 2A) becamemember of the Mayo research team that was perform-

ng truly groundbreaking cardiovascular research. Afterompleting his scholarship, Rastelli remained at the

ayo Clinic as a research assistant (1962–1964) andesearch associate (1964–1968). During those years, Ras-elli worked tirelessly spending most of his time in thelinic, conducting research, and writing scientific papers.

Rastelli met his wife to be, Anna Anghileri, in 1959 inhe ski camp in Borneo, Italy when she was only 19 yearsld. While in America, he continued to correspond withnna almost daily. On August 11, 1964, Rastelli returned

o Italy and 1 day later married Anna Anghileri. Shortlyhereafter, they traveled to the United States. Rastelli had

happy, loving family, an interesting and productiverofession, and the future looked extremely promising.owever, a few days after his honeymoon, Rastelli wasiagnosed with Hodgkin’s disease. Even today, withodern chemotherapy, the overall 5-year survival rateith all cases of Hodgkin’s disease is only 55% to 60%,

lthough patients with stage I or stage II disease have a-year survival of about 80%. Rastelli was certainly awaref his poor prognosis, yet he chose to get the most fromhe years left to him.

In 1965, Rastelli received the Allen Welkind Award forutstanding research in cardiovascular surgery. In 1966,astelli’s daughter Antonella Luisa was born. In late966, Rastelli became increasingly symptomatic. Despite

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o work fervently. It is during this period that he devel-ped the classification of atrioventricular (AV) canal [1]nd the surgical procedure [2, 3] that bears his name, (ie,the Rastelli classification” and “the Rastelli operation”).uring this time, Rastelli received the Mayo Clinic Staffemorial Award in 1968 for his outstanding researchork, and the American Medical Association awarded

he Gold Medal to Rastelli for 2 consecutive years [4].ore precisely, the medals were awarded to two exhibits,

ig 1. (A) Giancarlo Rastelli during mountain trekking, ca 1955. (B)r. Rastelli during his residency in Parma, ca 1958. (Courtesy ofosangela Rastelli Zavattaro.)

ig 2. (A) Dr Rastelli upon arrival to Mayolinic in 1961. (B) Dr Giancarlo Rastelli,wight C. McGoon, and Jack L. Titus discuss-

ng Rastelli’s operation in front of their exhibitt the American Medical Association meetingn 1969. (Courtesy of Mayo Clinic Foundation.)

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f which Rastelli was a coauthor (Fig 2B). The first washe Billings Gold Medal in 1968 for anatomical classifica-ion of the atrioventricular canal that facilitated theevelopment of a new surgical technique [1]. The tech-ique was quickly adopted by his colleagues at the Mayolinic (Drs John W. Kirklin and Dwight C. McGoon

1925–1999]). The second medal was the Hektoen Goldedal for developing an operation using an extracardiac

onduit for surgical correction of truncus arteriosus [4].n 1968, Rastelli was appointed head of cardiovascularesearch at the Mayo Clinic, but his tenure was to behort-lived. Doctor Rastelli died at the Methodist Hospi-al in Rochester on February 2, 1970 at the age of 36 years.

he Rastelli Classification

n the early 1960s, Rastelli devoted much of his researchime to the understanding of the morphology of theommon AV canal and published several articles on theubject [5–7]. This allowed him to classify all forms of theomplete AV canals into 3 major types. In 1967, Rastelli,irklin and Kincaid published an article describing clas-

ification of the common AV canal [7]. The classifications based on the morphology of the anterior bridgingeaflet, and is comprised of types A, B, and C (Fig 3). Inhe subsequent year, Rastelli and his colleagues pub-ished an article describing their experience with theurgical repair of the complete AV canal in 38 patientsperated on at the Mayo Clinic between December 1955nd September 1967. The hospital mortality was 60%efore 1964 and this decreased to 20% for those operatedn between 1964 and 1967 [1]. The authors concluded thatthe recognition of three anatomic types of completetrioventricular canal has given a better understanding ofhe problems involved in surgical repair” [1].

Rastelli was very eager to publish a monograph on AVanal defects. Among the several projects that entirelyngrossed Rastelli during his last years, this monographas one of the most important. Acutely aware of the

apid progression of his disease, Rastelli was in a hurry tonish the book, but it was left for the others to finish andublish it [8]. Dwight C. McGoon wrote in the introduc-

ion to this monograph: “Prerequisite to the accurate and

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herefore the successful repair of any cardiac deformity isprecise understanding of its anatomic characteristics.

uch was not available when the first surgical effortsere made to correct complete atrioventricular canal.imultaneously with the urgent need to develop a moreuccessful technique was the investigation by Gian Ras-elli, under the tutelage of Drs Jack Titus and Johnirklin, of the characteristics of this anomaly and ulti-ately of its anatomic classification. The result was a

trikingly improved outlook for the child born with thisffliction, and thus also represents one of Gian’s moreignificant contributions” [8].

Much progress has been made since the first successfulepairs of AV canal reported by Rastelli and colleagues.n the most recent study of 209 children operated on foromplete AV canal at the Hospital for Sick Children inoronto between 1995 and 2002, operative mortality wasnly 2.9% [9]. However, it should be remembered that theodern advances in AV canal repair would not be

ossible without the early work of Rastelli and his accu-ate classification.

he Rastelli Operation

n 1967, Rastelli and colleagues described an experimen-al approach to the repair of truncus arteriosus by meansf aortic homograft used as a right ventricular outflow [3].he technique evolved into an operation applicable to areat variety of cardiac anomalies, including those chil-ren born with transposition of the great arteries (TGA),

ig 3. Rastelli classification of complete common atrioventricular canal.ortions, one mitral valve (MV) and one tricuspid valve (TV), attached mosterior common AV leaflet, MV and TV portions are not separated. (LV leaflet is divided but not attached to the septum. Mitral and tricuspid

ng in right ventricle near septum. Free interventricular communication onterior common AV leaflet is not divided and is not attached to the sep

ic cusps, occurs underneath this leaflet. (Reprinted from Rastelli GC, et a

entricular septal defect (VSD), and pulmonary stenosis a

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2]. The Rastelli operation was the first procedure de-cribed for TGA that incorporated the left ventricle intohe systemic circulation (Fig 4). This procedure was firsterformed by Dr Robert B. Wallace (1931–) at the Mayolinic on July 26, 1968 [10]. The operation opened possi-ilities for total correction of many congenital anomalies,

ncluding persistent truncus arteriosus and pulmonarytresia with VSD. In 1969, the world’s first successfulepair of truncus arteriosus was performed at the Mayolinic using the technique described by Rastelli [11].oday the term “Rastelli operation” is often applied

oosely to describe any operation in which the VSD islosed in a way that leaves the aorta coming from theorphologic LV, whereas the morphologic right ventricle

s connected to the pulmonary artery by means of extra-ardiac conduit. The Rastelli operation is indicated inatients with truncus arteriosus, VSD with pulmonarytresia, double outlet right ventricle, TGA with VSD andubpulmonary obstruction, and in congenitally correctedGA with pulmonary stenosis [12, 13].In a study of 160 patients with TGA who underwent the

astelli operation between 1968 and 1990 at the Mayolinic, and who were followed for at least 10 years, thereas an actuarial survival of 74% at 10 years and 59% at 20

ears [14]. This was despite an early mortality of 24% forhose operated on between 1968 and 1977, which de-reased to 4% for the patients operated on from 1988 to997. The outcome in the early patients was complicatedy pulmonary hypertension. A 10-year survival of 101atients with TGA who underwent the Rastelli operation

ype A: Anterior (A) common atrioventricular leaflet is divided into twolly to interventricular septum with long, nonfused chordae tendineae. Ineral; P � posterior; RA � right atrium.) (B) Type B: Anterior commononents are both attached medially to abnormal papillary muscle aris-under anterior common leaflet. (RV � right ventricle.) (C) Type C:o that free interventricular communication, extending to vicinity of aor-yo Clin Proc 1967;42:200–9 [7], with permission.)

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15]. Although the Rastelli operation has made an enor-ous impact, it is not without its flaws. Most of the

hildren who underwent the Rastelli operation will stillequire a conduit replacement at least once in their lives14–16]. A similar evolution of improvement has oc-urred for this surgery. In a review of 1,095 patients whonderwent a ventricle to pulmonary artery conduit at theayo Clinic, an early mortality for conduit replacement

n 306 patients operated between 1964 and 2001 was 4.9%,hich has decreased to 1.7% since 1989 [16].

pilogue

uring his last years, Rastelli worked long hours despitehe severity of his illness. In response to his sister’s pledgeo slow down and take it easy for a while, Rastelli once said:To stop the research is to cease to live.” He also continuedo support the patients who came to the Mayo Clinic fromtaly for surgical repair. During his last years, Rastelli

ig 4. (A–E) Rastelli operation. (A � aorta;nt. � anterior; IVC � inferior vena cava;A � pulmonary artery; RA � right atrium;V � right ventricle; SVC � superior vena

ava; TV � tricuspid valve; VSD � ventricu-ar septal defect.) (Reprinted from Rastelli GC,t al. Circulation 1969;39:83–95 [10], withermission.)

lways saw Italian patients before and after their surgery to F

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omfort them in their native language. He also kept a bigoster in his office that said, “Love always wins” (Fig 5A)igned by all his Italian patients.

One of Rastelli’s Italian patients was Vincenzo Fer-ante. Ferrante was a 12-year old boy with a diagnosis ofGA, VSD, and pulmonary stenosis who was first oper-ted on in Houston in 1966, when he underwent alalock-Hanlon operation. Ferrante went to Houston in969 for a follow-up in hopes of getting a complete repair,et he was considered to be inoperable. In despair,errante’s parents contacted Rastelli. Ferrante wasrought to the Mayo Clinic and underwent the Rastelliperation on November 11, 1969. The postoperativeourse was complicated and Ferrante was reoperated onn a week for recurrent VSD. Ferrante had to spend thehristmas season at the hospital. Although at the time Drastelli felt very sick, he visited Ferrante daily to keep hispirits high (Fig 5B), and once he spent the whole night aterrante’s bedside. Rastelli died less than 1 month after

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ate who is married and currently works as a civilngineer in Napoli, Italy. For him, Rastelli’s researchade the difference. It also made the difference for many

ther Italian children who signed the “Love always wins”oster in Dr. Rastelli’s office.Doctor Rastelli’s daughter Antonella Luisa was only 4hen her father died. She followed her father footsteps,raduated from medical school in Verona, Italy, completeder residency in internal medicine and became a staffhysician at Washington University in St. Louis, Missouri.Doctor Rastelli’s life was short, yet he accomplished

he work of many life times in only one. What he hadlanned for the future, we can only imagine. Disease wasot able to break his spirit but only fueled his creativity

nstead. His legacy lives on in the children helped by hisnnovations and in the continued application of theperation that carries his name.

e are grateful to Rosangela Rastelli Zavattaro, a sister of Driancarlo Rastelli, for providing us with unique photographs

nd detailed biographical information and to Drs Andrew N.edington, Richard Van Praagh, and Jack L. Titus for their mostaluable suggestions.

eferences

1. Rastelli GC, Ongley PA, Kirklin JW, McGoon DC. Surgicalrepair of the complete form of persistent common atrioven-tricular canal. J Thorac Cardiovasc Surg 1968;55:299–308.

2. Rastelli GC. A new approach to “anatomic” repair of trans-position of the great arteries. Mayo Clinic Proc 1969;44:1–12.

3. Rastelli GC, Titus JL, McGoon DC. Homograft of ascendingaorta and aortic valve as a right ventricular outflow. Anexperimental approach to the repair of truncus arteriosus.Arch Surg 1967;95:698–708.

4. Squarcia U, Squarcia A. Giancarlo Rastelli, MD. Mayo Clin

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5. Rastelli GC, Kirklin JW, Titus JL. Anatomic observations oncomplete form of persistent common atrioventricular canalwith special reference to atrioventricular valves. Mayo ClinProc 1966;41:296–308.

6. Rastelli GC, Weidman WH, Kirklin JW. Surgical repair of thepartial form of persistent common atrioventricular canalwith special reference to the problem of mitral valve incom-petence. Circulation 1965;31(Suppl 1):31–5.

7. Rastelli GC, Kirklin JW, Kincaid OW. Angiocardiography inpersistent common atrioventricular canal. Mayo Clin Proc1967;42:200–9.

8. Feldt RH, ed. Atrioventricular canal defects. Philadelphia:Saunders, 1976.

9. Fortuna RS, Ashburn DA, Carias De Oliveira N, et al. Atrio-ventricular septal defects: effect of bridging leaflet division onearly valve function. Ann Thorac Surg 2004;77:895–902.

0. Rastelli GC, Wallace RB, Ongley PA. Complete repair oftransposition of the great arteries with pulmonary stenosis: areview and report of a case corrected by using a new surgicaltechnique. Circulation 1969;39:83–95.

1. Wallace RB, Rastelli GC, Ongley PA, Titus JL, McGoon DC.Complete repair of truncus arteriosus defects. J ThoracCardiovasc Surg 1969;57:95–107.

2. Konstantinov IE, Williams WG. Atrial switch and Rastellioperation for congenitally corrected transposition with ven-tricular septal defect and pulmonary stenosis. Thorac Car-diovasc Surg 2003;8:160–6.

3. Ilbawi MN, DeLeon SY, Backer CL, et al. An alternativeapproach to the surgical management of physiologicallycorrected transposition with pulmonary stenosis or atresia.J Thorac Cardiovasc Surg 1990;100:410–5.

4. Dearani JA, Danielson GK, Puga FJ, et al. Late results of theRastelli operation for transposition of the great arteries.Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu2001;4:3–15.

5. Kreutzer C, DeVive J, Oppido G, et al. Twenty-five yearexperience with Rastelli repair for transposition of the greatarteries. J Thorac Cardiovasc Surg 2000;120:211–23.

6. Dearani JA, Danielson GK, Puga FJ, et al. Late follow-upof 1,095 patients undergoing operation for complex con-genital heart disease utilizing pulmonary ventricle topulmonary artery conduits. Ann Thorac Surg 2003;75:399 –

Fig 5. (A) A poster signed by all Italian chil-dren operated on at the Mayo Clinic in the late1960s that Dr Rastelli kept in his office. TheItalian inscription on the poster says, “Lovealways wins.” (B) Vincenzo Ferrante a fewdays after the Rastelli operation with Dr Ras-telli at the Mayo Clinic in 1969. (Courtesy ofRosangela Rastelli Zavattaro with permissionof Vincenzo Ferrante.)

411.

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2005;79:1819-1823 Ann Thorac SurgAlexi-Meskishvili and Jia Li

Igor E. Konstantinov, Felice Rosapepe, Joseph A. Dearani, Vladimir V. A Tribute to Giancarlo Rastelli

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