Double Switch Operation for Congenitally Corrected Transposition and Severe Pulmonary Stenosis: Senning-Rastelli/Nikaidoh vs. Senning-En-Bloc Rotation: Is it Worth Going the Extra Mile to Avoid Right Ventricular Outflow Tract Obstructions?

All articles of this category (opens in new window) Background: In patients with complex congenitally corrected transposition of the great arteries (ccTGA) with severe pulmonary stenosis, the double switch operation (DSO) is traditionally carried out as atrial switch (AS) using the Senning/Mustard procedure in combination with either the Rastelli or Nikaidoh procedure. En-bloc rotation (ERAT) aims to prevent not only left but also right outflow tract obstructions (L-/RVOTO); however is technically more demanding. We are sharing our 10-year experience with AS-Rastelli/Nikaidoh vs. AS-ERAT. Methods: All ccTGA patients with severe pulmonary stenosis undergoing AS-Rastelli/Nikaidoh vs. AS-ERAT between March 2015 and January 2025 were included. Patients with mild resectable LVOTO were excluded. Preoperative baseline characteristics, procedural data, and early/mid-term outcomes were analyzed. Freedom from death and reoperations/reinterventions was estimated using Kaplan–Meier time-to-event models. Results: Out of 38 DSOs, we identified 16 patients, either undergoing AS-Rastelli/Nikaidoh ( n = 10; 8/2) or AS-ERAT ( n = 6). Median age and weight at surgery were 1.9 years (IQR: 0.7–6.9) and 10.9 kg (7.7–21.6), with no differences between the groups. Significantly longer aortic cross-clamp and bypass times ( p = 0.02) were noted in the ERAT group: median 219 minutes (208.3–260.5) and 373.5 (313–412.8) vs. 133.5 (122–167.8) and 247 (232.8–289.3) in the Rastelli/Nikaidoh group. Two patients (12.5%) died in the direct postoperative period, one adult with extremely hypertrophied subpulmonary LV needing mechanical support after AS-Nikaidoh, and another one after ERAT due to severe sepsis. One late death occurred after AS-Rastelli during pulmonary valve reoperation A total of three patients received pacemaker implantations, one after AS-Nikaidoh, two after AS-ERAT group: 12.5% vs.33.3%, p = 0.5. Median follow-up duration was 18.8 months (1.2–38.4). 5-year survival was 66.7% (16.1–91.4) after AS-Rastelli/Nikaidoh vs. 80% (23.4–96.9) after AS-ERAT, p = 0.8. 5-year freedom from LVOT-reoperation was 100% in both groups; freedom from RVOT-reoperation was 55.6% (7.3–87.6) after Rastelli/Nikaidoh vs. 100% after ERAT, p = 0.2. Conclusion: AS-ERAT for cc-TGA patients is complex but feasible in experienced centers. Early and mid-term outcomes are favorable in our small cohort, with a tendency toward higher freedom from RVOTOs. Longer follow-up times are needed to understand whether this more complex surgery will pay off by reducing outflow tract reinterventions. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany