A Tribute to Giancarlo Rastelli

Igor E. Konstantinov, Felice Rosapepe, Joseph A. Dearani, Vladimir V.

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

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The Annals of Thoracic Surgery is the official journal of The Society of Thoracic Surgeons and the
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A Tribute to Giancarlo Rastelli
Igor E. Konstantinov, MD, PhD, Felice Rosapepe, MD, PhD, Joseph A. Dearani, MD,
Vladimir V. Alexi-Meskishvili, MD, PhD, and Jia Li, MD, PhD
Division of Cardiovascular Surgery, Hospital for Sick Children, Toronto, Ontario, Canada; Department of Pediatric Cardiac
Surgery, Azienda Ospedaliera Monaldi, Napoli, Italy; Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minnesota;
Deutsches Herzzentrum Berlin, Berlin, Germany
Giancarlo Rastelli (1933–1970) was a pioneer cardiac
surgeon who developed a classification of atrioventricu-
lar canal and a novel surgical procedure that revolution-
ized the management of children with congenital heart
disease. Rastelli lived a short, yet fascinating life. His
work was ahead of its time and laid the foundation for
the treatment of complex congenital cardiac anomalies.
(Ann Thorac Surg 2005;79:1819 –23)
© 2005 by The Society of Thoracic Surgeons
Biographical Notes
G iancarlo Rastelli (1933–1970) was born on June 25,
1933 in Pescara, Italy. His father, Vito Rastelli, was
a journalist for a local newspaper. His mother, Luisa
Bianchi, was an elementary school teacher. Rastelli had a
younger sister Rosangela. She now lives in Milan, and
some biographical information presented herein is based
on her personal account. In 1945, Rastelli’s family moved
to Parma, the native town of both his parents. Here
Rastelli attended the Classic Lyceum of Romagna and
then studied medicine at the University of Parma. Ras-
telli was a hard-working student during his medical
school years, but he had also developed a passion for
both classical music and mountain trekking (Fig 1A). He
spent much of his spare time either listening to his
collection of records or exploring mountain paths. As a
medical student Rastelli completed his research projects
first at the department of anatomy directed by Professor
Gaetano Ottaviani from 1951 to 1953, and then at the
department of general pathology directed by Professor
Domenico Rezzi from 1953 to 1955. During those years
Rastelli developed a strong interest in the anatomy and
pathology of the heart. Rastelli graduated cum laude in
1957 and won “Le Petit” prize for the best graduation
thesis entitled “Changes in the ATPase activity of the
myocardium during deep hypothermia.” In 1957, Rastelli
began his training in surgery at the department of sur-
gery headed by Professor Antonio Bobbio at the Univer-
sity of Parma Hospital. At that time, Rastelli’s particular
interest was in diagnostic techniques (Fig 1B).
Being a compassionate person, Rastelli always tried to
explain to his patient the exact underlying cause of the
illness, as well as the anatomy, pathology, and treatment
options. Yet Rastelli often did not have an answer for his
patients, nor did he have a surgical option to offer to his
Address reprint requests to Dr Konstantinov, Division of Cardiovascular
Surgery, Hospital for Sick Children, 555 University Ave, Toronto M5G
1X8, Ontario, Canada; e-mail: igorkonst@hotmail.com.
© 2005 by The Society of Thoracic Surgeons
Published by Elsevier Inc
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OUR SURGICAL HERITAGE
patients with congenital cardiac malformations. This
quest for answers stimulated Rastelli, together with an-
other surgical trainee, Dr Carlo Battistini, to undertake
intense surgical research. Drs Battistini, Bobbio, and
Rastelli also shared a passion for classical music. They
spent hours together listening to classical music records
and discussing a variety of subjects. This friendship also
facilitated successful research because they worked very
effectively as a team. This productive teamwork helped
Rastelli win a North Atlantic Treaty Organization
(NATO) scholarship in 1960 that allowed him to continue
his studies at the Mayo Clinic.
Rastelli’s choice of the Mayo Clinic was inspired by the
pioneering work of John W. Kirklin (1917–2004), who
truly revolutionized heart surgery in the 1950s using the
Mayo-Gibbon heart-lung machine. Doctor Kirklin be-
came professor and chairman of the department of sur-
gery at the Mayo Clinic in 1960, and he held the latter
position until 1966 when he became chairman of the
department of surgery at the University of Alabama.
Inspired by the work of Kirklin, Rastelli (Fig 2A) became
a member of the Mayo research team that was perform-
ing truly groundbreaking cardiovascular research. After
completing his scholarship, Rastelli remained at the
Mayo Clinic as a research assistant (1962–1964) and
research associate (1964 –1968). During those years, Ras-
MISCELLANEOUS
telli worked tirelessly spending most of his time in the
clinic, conducting research, and writing scientific papers.
Rastelli met his wife to be, Anna Anghileri, in 1959 in
the ski camp in Borneo, Italy when she was only 19 years
old. While in America, he continued to correspond with
Anna almost daily. On August 11, 1964, Rastelli returned
to Italy and 1 day later married Anna Anghileri. Shortly
thereafter, they traveled to the United States. Rastelli had
a happy, loving family, an interesting and productive
profession, and the future looked extremely promising.
However, a few days after his honeymoon, Rastelli was
diagnosed with Hodgkin’s disease. Even today, with
modern chemotherapy, the overall 5-year survival rate
with all cases of Hodgkin’s disease is only 55% to 60%,
although patients with stage I or stage II disease have a
5-year survival of about 80%. Rastelli was certainly aware
of his poor prognosis, yet he chose to get the most from
the years left to him.
In 1965, Rastelli received the Allen Welkind Award for
outstanding research in cardiovascular surgery. In 1966,
Rastelli’s daughter Antonella Luisa was born. In late
1966, Rastelli became increasingly symptomatic. Despite
being fully aware of his bleak future, Rastelli continued
0003-4975/05/$30.00
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 1820 OUR SURGICAL HERITAGE KONSTANTINOV ET AL
GIANCARLO RASTELLI TRIBUTE
Fig 1. (A) Giancarlo Rastelli during mountain trekking, ca 1955. (B)
Dr. Rastelli during his residency in Parma, ca 1958. (Courtesy of
Rosangela Rastelli Zavattaro.)
to work fervently. It is during this period that he devel-
oped the classification of atrioventricular (AV) canal [1]
MISCELLANEOUS
and the surgical procedure [2, 3] that bears his name, (ie,
“the Rastelli classification” and “the Rastelli operation”).
During this time, Rastelli received the Mayo Clinic Staff
Memorial Award in 1968 for his outstanding research
work, and the American Medical Association awarded
the Gold Medal to Rastelli for 2 consecutive years [4].
More precisely, the medals were awarded to two exhibits,
Fig 2. (A) Dr Rastelli upon arrival to Mayo
Clinic in 1961. (B) Dr Giancarlo Rastelli,
Dwight C. McGoon, and Jack L. Titus discuss-
ing Rastelli’s operation in front of their exhibit
at the American Medical Association meeting
in 1969. (Courtesy of Mayo Clinic Foundation.)
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Ann Thorac Surg
2005;79:1819 –23
of which Rastelli was a coauthor (Fig 2B). The first was
the Billings Gold Medal in 1968 for anatomical classifica-
tion of the atrioventricular canal that facilitated the
development of a new surgical technique [1]. The tech-
nique was quickly adopted by his colleagues at the Mayo
Clinic (Drs John W. Kirklin and Dwight C. McGoon
[1925–1999]). The second medal was the Hektoen Gold
Medal for developing an operation using an extracardiac
conduit for surgical correction of truncus arteriosus [4].
In 1968, Rastelli was appointed head of cardiovascular
research at the Mayo Clinic, but his tenure was to be
short-lived. Doctor Rastelli died at the Methodist Hospi-
tal in Rochester on February 2, 1970 at the age of 36 years.
The Rastelli Classification
In the early 1960s, Rastelli devoted much of his research
time to the understanding of the morphology of the
common AV canal and published several articles on the
subject [5–7]. This allowed him to classify all forms of the
complete AV canals into 3 major types. In 1967, Rastelli,
Kirklin and Kincaid published an article describing clas-
sification of the common AV canal [7]. The classification
is based on the morphology of the anterior bridging
leaflet, and is comprised of types A, B, and C (Fig 3). In
the subsequent year, Rastelli and his colleagues pub-
lished an article describing their experience with the
surgical repair of the complete AV canal in 38 patients
operated on at the Mayo Clinic between December 1955
and September 1967. The hospital mortality was 60%
before 1964 and this decreased to 20% for those operated
on between 1964 and 1967 [1]. The authors concluded that
“the recognition of three anatomic types of complete
atrioventricular canal has given a better understanding of
the problems involved in surgical repair” [1].
Rastelli was very eager to publish a monograph on AV
canal defects. Among the several projects that entirely
engrossed Rastelli during his last years, this monograph
was one of the most important. Acutely aware of the
rapid progression of his disease, Rastelli was in a hurry to
finish the book, but it was left for the others to finish and
publish it [8]. Dwight C. McGoon wrote in the introduc-
tion to this monograph: “Prerequisite to the accurate and
Ann Thorac Surg OUR SURGICAL HERITAGE KONSTANTINOV ET AL 1821
2005;79:1819 –23 GIANCARLO RASTELLI TRIBUTE

Fig 3. Rastelli classification of complete common atrioventricular canal. (A) Type A: Anterior (A) common atrioventricular leaflet is divided into two
portions, one mitral valve (MV) and one tricuspid valve (TV), attached medially to interventricular septum with long, nonfused chordae tendineae. In
posterior common AV leaflet, MV and TV portions are not separated. (L ⫽ lateral; P ⫽ posterior; RA ⫽ right atrium.) (B) Type B: Anterior common
AV leaflet is divided but not attached to the septum. Mitral and tricuspid components are both attached medially to abnormal papillary muscle aris-
ing in right ventricle near septum. Free interventricular communication occurs under anterior common leaflet. (RV ⫽ right ventricle.) (C) Type C:
Anterior common AV leaflet is not divided and is not attached to the septum so that free interventricular communication, extending to vicinity of aor-
tic cusps, occurs underneath this leaflet. (Reprinted from Rastelli GC, et al. Mayo Clin Proc 1967;42:200 –9 [7], with permission.)

therefore the successful repair of any cardiac deformity is
a precise understanding of its anatomic characteristics.
Such was not available when the first surgical efforts
were made to correct complete atrioventricular canal.
Simultaneously with the urgent need to develop a more
successful technique was the investigation by Gian Ras-
telli, under the tutelage of Drs Jack Titus and John
[2]. The Rastelli operation was the first procedure de-
scribed for TGA that incorporated the left ventricle into
the systemic circulation (Fig 4). This procedure was first
performed by Dr Robert B. Wallace (1931–) at the Mayo
Clinic on July 26, 1968 [10]. The operation opened possi-
bilities for total correction of many congenital anomalies,
including persistent truncus arteriosus and pulmonary

Kirklin, of the characteristics of this anomaly and ulti-
mately of its anatomic classification. The result was a
strikingly improved outlook for the child born with this
affliction, and thus also represents one of Gian’s more
significant contributions” [8].
Much progress has been made since the first successful
repairs of AV canal reported by Rastelli and colleagues.
In the most recent study of 209 children operated on for
complete AV canal at the Hospital for Sick Children in
Toronto between 1995 and 2002, operative mortality was
only 2.9% [9]. However, it should be remembered that the
modern advances in AV canal repair would not be
possible without the early work of Rastelli and his accu-
rate classification.
The Rastelli Operation
In 1967, Rastelli and colleagues described an experimen-
tal approach to the repair of truncus arteriosus by means
of aortic homograft used as a right ventricular outflow [3].
The technique evolved into an operation applicable to a
great variety of cardiac anomalies, including those chil-
dren born with transposition of the great arteries (TGA),
ventricular septal defect (VSD), and pulmonary stenosis
MISCELLANEOUS
atresia with VSD. In 1969, the world’s first successful
repair of truncus arteriosus was performed at the Mayo
Clinic using the technique described by Rastelli [11].
Today the term “Rastelli operation” is often applied
loosely to describe any operation in which the VSD is
closed in a way that leaves the aorta coming from the
morphologic LV, whereas the morphologic right ventricle
is connected to the pulmonary artery by means of extra-
cardiac conduit. The Rastelli operation is indicated in
patients with truncus arteriosus, VSD with pulmonary
atresia, double outlet right ventricle, TGA with VSD and
subpulmonary obstruction, and in congenitally corrected
TGA with pulmonary stenosis [12, 13].
In a study of 160 patients with TGA who underwent the
Rastelli operation between 1968 and 1990 at the Mayo
Clinic, and who were followed for at least 10 years, there
was an actuarial survival of 74% at 10 years and 59% at 20
years [14]. This was despite an early mortality of 24% for
those operated on between 1968 and 1977, which de-
creased to 4% for the patients operated on from 1988 to
1997. The outcome in the early patients was complicated
by pulmonary hypertension. A 10-year survival of 101
patients with TGA who underwent the Rastelli operation
at Boston Children’s Hospital from 1973 to 1998 was 70%

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 1822 OUR SURGICAL HERITAGE KONSTANTINOV ET AL
GIANCARLO RASTELLI TRIBUTE
Fig 4. (A–E) Rastelli operation. (A ⫽ aorta;
Ant. ⫽ anterior; IVC ⫽ inferior vena cava;
PA ⫽ pulmonary artery; RA ⫽ right atrium;
RV ⫽ right ventricle; SVC ⫽ superior vena
cava; TV ⫽ tricuspid valve; VSD ⫽ ventricu-
lar septal defect.) (Reprinted from Rastelli GC,
et al. Circulation 1969;39:83–95 [10], with
permission.)
MISCELLANEOUS
[15]. Although the Rastelli operation has made an enor-
mous impact, it is not without its flaws. Most of the
children who underwent the Rastelli operation will still
require a conduit replacement at least once in their lives
[14 –16]. A similar evolution of improvement has oc-
curred for this surgery. In a review of 1,095 patients who
underwent a ventricle to pulmonary artery conduit at the
Mayo Clinic, an early mortality for conduit replacement
in 306 patients operated between 1964 and 2001 was 4.9%,
which has decreased to 1.7% since 1989 [16].
Epilogue
During his last years, Rastelli worked long hours despite
the severity of his illness. In response to his sister’s pledge
to slow down and take it easy for a while, Rastelli once said:
“To stop the research is to cease to live.” He also continued
to support the patients who came to the Mayo Clinic from
Italy for surgical repair. During his last years, Rastelli
always saw Italian patients before and after their surgery to
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Ann Thorac Surg
2005;79:1819 –23
comfort them in their native language. He also kept a big
poster in his office that said, “Love always wins” (Fig 5A)
signed by all his Italian patients.
One of Rastelli’s Italian patients was Vincenzo Fer-
rante. Ferrante was a 12-year old boy with a diagnosis of
TGA, VSD, and pulmonary stenosis who was first oper-
ated on in Houston in 1966, when he underwent a
Blalock-Hanlon operation. Ferrante went to Houston in
1969 for a follow-up in hopes of getting a complete repair,
yet he was considered to be inoperable. In despair,
Ferrante’s parents contacted Rastelli. Ferrante was
brought to the Mayo Clinic and underwent the Rastelli
operation on November 11, 1969. The postoperative
course was complicated and Ferrante was reoperated on
in a week for recurrent VSD. Ferrante had to spend the
Christmas season at the hospital. Although at the time Dr
Rastelli felt very sick, he visited Ferrante daily to keep his
spirits high (Fig 5B), and once he spent the whole night at
Ferrante’s bedside. Rastelli died less than 1 month after
Ferrante’s discharge. Now Ferrante is a university grad-
Ann Thorac Surg
2005;79:1819 –23
uate who is married and currently works as a civil
engineer in Napoli, Italy. For him, Rastelli’s research
made the difference. It also made the difference for many
other Italian children who signed the “Love always wins”
poster in Dr. Rastelli’s office.
Doctor Rastelli’s daughter Antonella Luisa was only 4
when her father died. She followed her father footsteps,
graduated from medical school in Verona, Italy, completed
her residency in internal medicine and became a staff
physician at Washington University in St. Louis, Missouri.
Doctor Rastelli’s life was short, yet he accomplished
the work of many life times in only one. What he had
planned for the future, we can only imagine. Disease was
not able to break his spirit but only fueled his creativity
instead. His legacy lives on in the children helped by his
innovations and in the continued application of the
operation that carries his name.
We are grateful to Rosangela Rastelli Zavattaro, a sister of Dr
Giancarlo Rastelli, for providing us with unique photographs
and detailed biographical information and to Drs Andrew N.
Redington, Richard Van Praagh, and Jack L. Titus for their most
valuable suggestions.
References
1. Rastelli GC, Ongley PA, Kirklin JW, McGoon DC. Surgical
repair 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 ascending
aorta and aortic valve as a right ventricular outflow. An
experimental approach to the repair of truncus arteriosus.
Arch Surg 1967;95:698 –708.
4. Squarcia U, Squarcia A. Giancarlo Rastelli, MD. Mayo Clin
Proc 2001;76:874.
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OUR SURGICAL HERITAGE KONSTANTINOV ET AL 1823
GIANCARLO RASTELLI TRIBUTE
Fig 5. (A) A poster signed by all Italian chil-
dren operated on at the Mayo Clinic in the late
1960s that Dr Rastelli kept in his office. The
Italian inscription on the poster says, “Love
always wins.” (B) Vincenzo Ferrante a few
days after the Rastelli operation with Dr Ras-
telli at the Mayo Clinic in 1969. (Courtesy of
Rosangela Rastelli Zavattaro with permission
of Vincenzo Ferrante.)
5. Rastelli GC, Kirklin JW, Titus JL. Anatomic observations on
complete form of persistent common atrioventricular canal
with special reference to atrioventricular valves. Mayo Clin
Proc 1966;41:296 –308.
6. Rastelli GC, Weidman WH, Kirklin JW. Surgical repair of the
partial form of persistent common atrioventricular canal
with 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 in
persistent common atrioventricular canal. Mayo Clin Proc
1967;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 on
MISCELLANEOUS
early valve function. Ann Thorac Surg 2004;77:895–902.
10. Rastelli GC, Wallace RB, Ongley PA. Complete repair of
transposition of the great arteries with pulmonary stenosis: a
review and report of a case corrected by using a new surgical
technique. Circulation 1969;39:83–95.
11. Wallace RB, Rastelli GC, Ongley PA, Titus JL, McGoon DC.
Complete repair of truncus arteriosus defects. J Thorac
Cardiovasc Surg 1969;57:95–107.
12. Konstantinov IE, Williams WG. Atrial switch and Rastelli
operation for congenitally corrected transposition with ven-
tricular septal defect and pulmonary stenosis. Thorac Car-
diovasc Surg 2003;8:160 – 6.
13. Ilbawi MN, DeLeon SY, Backer CL, et al. An alternative
approach to the surgical management of physiologically
corrected transposition with pulmonary stenosis or atresia.
J Thorac Cardiovasc Surg 1990;100:410 –5.
14. Dearani JA, Danielson GK, Puga FJ, et al. Late results of the
Rastelli operation for transposition of the great arteries.
Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu
2001;4:3–15.
15. Kreutzer C, DeVive J, Oppido G, et al. Twenty-five year
experience with Rastelli repair for transposition of the great
arteries. J Thorac Cardiovasc Surg 2000;120:211–23.
16. Dearani JA, Danielson GK, Puga FJ, et al. Late follow-up
of 1,095 patients undergoing operation for complex con-
genital heart disease utilizing pulmonary ventricle to
pulmonary artery conduits. Ann Thorac Surg 2003;75:399 –
411.
 A Tribute to Giancarlo Rastelli
Igor E. Konstantinov, Felice Rosapepe, Joseph A. Dearani, Vladimir V.
Alexi-Meskishvili and Jia Li
Ann Thorac Surg 2005;79:1819-1823

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