Pulmonary Artery Banding Treatment & Management
- Author: Shabir Bhimji, MD, PhD; Chief Editor: John Kupferschmid, MD more...
Preoperative treatment of patients with pulmonary overcirculation and congestive heart failure (CHF) should focus on minimizing left-to-right shunting, improving cardiac function with inotropic support, systemic afterload reduction, and aggressive diuresis. Mechanical ventilator support may be necessary to maintain adequate ventilation and oxygenation in the setting of pulmonary edema. Maintaining higher carbon dioxide levels and lower fraction of inspired oxygen (FIO2) during ventilation may assist in reducing pulmonary blood flow (PBF) and pulmonary edema. If a patent ductus arteriosus (PDA) is present, attempts should be made to reduce or close it with medical therapy (eg, indomethacin) to reduce this source of PBF.
In the surgical treatment of congenital heart defects, pulmonary artery banding is a palliative intervention that is performed as a staged approach to a more definitive surgical repair. The goals of pulmonary artery banding include reduction of PBF to reduce left-to-right shunting and CHF, protection of the pulmonary vasculature from hypertensive changes, and training of the left ventricle (LV) in anticipation of an arterial switch procedure.
Three standard surgical approaches to pulmonary artery banding (PAB) have been established, depending on the need to perform additional procedures at the time of band placement. As an isolated procedure, pulmonary artery banding can be performed through an anterior left thoracotomy in the second or third interspace (see following image).
If performed in conjunction with a coarctation or interrupted aortic arch repair, a left lateral thoracotomy is used and the chest is entered through the third or fourth intercostal space. In both of these approaches, the pericardium is incised anterior to the left phrenic nerve and the thymus is retracted to expose the main pulmonary artery (MPA). A third approach is through a median sternotomy for conditions in which intracardiac procedures (eg, atrial septectomy, partial Senning procedure) requiring cardiopulmonary bypass are indicated. A median sternotomy may also be used in patients with malposed or transposed great vessels in which direct access to the MPA is limited by the position of the aorta through a left thoracotomy approach.
Patients may benefit from placement of a band that can be easily and quickly tightened or loosened, both at the initial procedure and during subsequent interventions. The ability to readjust the band is particularly useful in patients who exhibit dynamic changes in cardiac output, pulmonary vascular resistance, and systemic vascular resistance. Additionally, it may benefit patients with significant lung disease (eg, pulmonary edema, atelectasis, pneumonia). Such patients develop severe arterial oxygen desaturation with pulmonary artery banding but may tolerate gradually increasing band tightness as the pulmonary process resolves.
Adjustable bands are also helpful in patients with AV valve regurgitation, particularly complex AV canal defects. The acute increase in afterload that accompanies pulmonary artery banding may exacerbate AV valve insufficiency. Staged tightening of the band is usually well tolerated and allows improvement in insufficiency by decreasing ventricular volume overload. Given the advantages of the adjustable band, this technique is routinely used at the UCLA Medical Center.[37, 38]
The MPA and aorta are exposed, and the band is prepared for placement. Various banding materials are available, but the authors prefer to use umbilical tape. This material is broad enough to minimize risk of eroding through the PA wall but can still be passed easily through a silastic snare for use as an adjustable band.
The estimated band circumference is marked on the umbilical tape with fine sutures according to the Trusler formula.[39, 40] Pulmonary artery banding circumference in patients with noncyanotic nonmixing lesions (eg, ventricular septal defect [VSD]) is 20 mm + 1 mm/kg body weight. For patients with mixing lesions (eg, D-transposition of the great arteries [TGA] with VSD), the formula is 24 mm + 1 mm/kg body weight. In patients with single ventricles in whom the Fontan procedure is planned, an intermediate circumference of 22 mm + 1 mm/kg body weight is preferred. Note that these estimates of band circumference are used simply as guidelines and that the final tightness of the band is ultimately determined by the surgeon using blood gas and PAP measurements at the time of surgery.
The site of band placement is carefully selected in the mid portion of the MPA trunk, and distortion or injury to the pulmonary valve or impingement on the branch pulmonary arteries is avoided. Dissection is performed in the adventitia between the aorta and the MPA, and it is limited to prevent proximal or distal band migration. The MPA is handled very carefully because it often is dilated, thin-walled, and susceptible to injury. Regardless of the operative approach, injuries to the posterior wall of the MPA can be difficult to repair because of limited exposure.
Generally, the band is first passed through the transverse sinus to encircle both the aorta and MPA. The aortic end of the band is then carefully delivered between the aorta and the MPA through the previous site of dissection (see following image).
With this technique, the clamp is never passed around the MPA alone and avoids injuries to the artery. This technique is particularly important when pulmonary artery banding is performed through a left thoracotomy on a patient with malposed great vessels.
The marked sites on the band are identified and aligned with each other on the anterior wall of the MPA. The band is snared with a short segment of #8 or #10 polyethylene tubing and fixed with medium hemoclips. A felt or pericardial pledget is placed beneath the band between the end of the snare and the MPA wall to prevent injury to the artery from the snare. The pledget and band material are then anchored to the MPA adventitia to prevent band migration (see following image).
Tightening the band by the addition of one medium hemoclip is approximately equivalent to a 1-mm decrease in the band circumference. Conversely, removal of a hemoclip enlarges the circumference approximately 1 mm. Instruments for hemoclip application and removal are kept with the patient in the intensive care unit to allow rapid tightening or loosening of the band if necessary. Note that with this technique, no cases of infection or erosion related to the snare have been reported.
Previous experience by the authors' group and others has documented that, although a band is adequate at the time of placement, it may become "too loose" over subsequent weeks and months. This can represent resorption of the internal folds of the vessel wall that are initially present when a circumferential band is placed (see following image).
These acute infoldings of the artery wall further decrease the cross-sectional area of the PA. However, these infoldings resorb with time, restoring a smooth wall and a greater internal cross-sectional area of lumen, a greater PBF, and thus, a looser band.
The authors have modified their technique by decreasing the diameter of the MPA (incisional technique) before applying the band. A partially occluding C clamp is applied to half of the diameter of the MPA distal to the sinotubular junction (see following image).
A perpendicular incision is made into the excluded portion of the artery. The deep V-shaped arteriotomy is closed with a running suture, effectively reducing the diameter of the artery by 40%. An umbilical tape is used with an adjustable snare as described earlier.
In the authors' experience, the incisional pulmonary artery banding has produced a more stable band gradient over time with less requirement for subsequent tightening. It has also eliminated the complication of band migration distally and impingement on the branch pulmonary arteries.
Physiologic assessment to determine the appropriate tightness of the pulmonary artery banding includes intraoperative measurements of the proximal and distal PA pressures, systemic blood pressure, and arterial oxygen saturation by pulse oximetry (or by direct measurement of arterial blood gas sampling). The goal of pulmonary artery banding is to produce a distal PA pressure that is 30-50% of systemic pressure. In general, the authors attempt to achieve saturations of approximately 85-90% with an FIO2 of 50%. Lower saturations of 75-80% may be acceptable in patients with single ventricle physiology. Failure to achieve these levels in patients with mixed circulations suggests inadequacy of the interatrial communication. In such patients, addition of an atrial septectomy or septostomy may be indicated. In addition to changes in PA pressure and systemic oxygen saturation, one ideally should note a concomitant rise in systemic arterial pressure of 10-15 mm Hg.
One technique applied in patients has been a partial atrial baffle with pulmonary artery banding (see following image).
With this procedure, the inferior vena caval blood is directed toward the pulmonary (left) ventricle through a pericardial patch baffle. This represents approximately two thirds of systemic desaturated venous return. Conversely, saturated blood returning from the lungs through the right pulmonary veins is directed around the baffle toward the systemic (right) ventricle. This "favorable streaming" results in improvements in saturation and allows placement of an adequately tight pulmonary artery banding for preparation of the LV. This procedure also provides long-term palliation for patients who may not be candidates for the arterial switch procedure. Pulmonary artery banding in conjunction with a modified Blalock-Taussig shunt is performed as a closed procedure without CPB and, therefore, is a more desirable approach for short-term preparation of the LV.
Pulmonary artery banding takedown is usually performed at the time of the intracardiac repair through a median sternotomy. Generally, the repair is completed first and the pulmonary artery banding removal is performed at the end of the procedure. The band is dissected free from surrounding scar tissue and removed. The area of banding usually remains stenotic and requires repair. This repair can be achieved by resection and end-to-end anastomosis of the proximal and distal MPA or by vertical incision of the MPA followed by pericardial (or polytetrafluoroethylene [PTFE]) patch repair of the arteriotomy (see following image).
The repair must ensure relief of any branch PA stenosis that may exist as a consequence of the pulmonary artery banding.
Patients undergoing PAB are initially treated in the intensive care unit (ICU). They often benefit from a course of intravenous inotropic support and require careful attention to fluid balance and volume status. Following PAB, improved hemodynamics and greater left ventricular output often allow for diuresis and gradual resolution of CHF. The assessment of a patient following PAB should ideally be made under conditions of balanced volume status and in the absence of atelectasis or ongoing pulmonary pathology. Although measured parameters from the operating room are helpful guidelines, the overall clinical status of the patient is the most important assessment. This includes changes in systemic blood pressure, heart rate, oxygen saturation, and overall cardiac function. Hypotension, bradycardia, and ischemic electrocardiographic changes all indicate an excessive band gradient and imminent cardiac failure or arrest.
The advantage of an adjustable PAB is that it allows for rapid loosening of the band with a hemoclip remover in the ICU, if necessary. Catheter debanding is also an invaluable technique in selected cases.
Evaluation of the PAB is made by color flow Doppler echocardiography at the bedside; it usually provides an accurate assessment of band tightness, band gradient, band position, and overall cardiac function. Any impingement or stenosis of the branch pulmonary arteries can also be observed with this study. Rarely, cardiac catheterization and direct measurement of PA pressure and band gradient is necessary. More recently, cinemagnetic resonance imaging and 3-dimensional reconstruction have been useful as noninvasive methods of evaluation.
Most patients undergoing pulmonary artery banding for pulmonary overcirculation are monitored for 3-6 months and then undergo more definitive repair of their cardiac defect. Note that the degree of right ventricular hypertrophy that develops in response to any given pulmonary artery banding gradient varies greatly among infants. Those infants who develop rapid and severe right ventricular hypertrophy in response to pulmonary artery banding should be considered for earlier definitive repair to prevent long-term right ventricular dysfunction.
Patients with D-TGA who undergo pulmonary artery banding for training of the LV must be monitored with serial echocardiography to assess "readiness" of the LV before the arterial switch operation. After either technique, patients are monitored with serial echocardiography that allows quantitative measurements of left ventricular mass index, as well as qualitative assessment of ventricular septal geometry. Left-to-right septal bowing is an indication that the LV can generate near-systemic pressure. Left ventricular preparation is usually accomplished within 7-10 days, after which patients may undergo an arterial switch procedure, takedown of shunt, and pulmonary artery banding. The early mortality rate is 4-5%, only slightly greater than that for a primary arterial switch procedure.[44, 45] In infants, this may be several weeks, but older children may require longer periods of banding to achieve adequate results.
In one recent study, infants who required bilateral pulmonary artery banding as a part of temporary stabling treatment for hypoplastic left heart commonly required additional interventions. Those with a small band applied for longer duration were at the highest risk for interventions.
Although pulmonary artery banding (PAB) is a seemingly simple operation, it has been associated with numerous complications. One of the most common complications of pulmonary artery banding is impingement and stenosis of one or both of the branch pulmonary arteries. The right pulmonary artery (PA) is involved in most cases of branch stenosis for anatomic reasons already mentioned.
The diagnosis of branch PA impingement is often suggested by a chest radiograph that shows asymmetric vascular markings between the right and left lungs. Definitive diagnosis can usually be made by echocardiography, and fractional pulmonary blood flow (PBF) to each lung can be determined with radionuclide lung perfusion scanning. If significant branch stenosis is uncorrected, it can lead to underdevelopment of the involved lung with alveolar hypoplasia. Early recognition of branch PA stenosis should allow a revision of the pulmonary artery banding before the development of this late sequela. Limiting dissection of the tissue between the aorta and the main pulmonary artery (MPA) and fixing the band with sutures on the proximal MPA adventitia both reduce risk of this complication. Use of the incisional pulmonary artery banding technique prevents distal band migration and generally avoids this complication.
Conversely, if the band is placed too proximal on the MPA, it may distort the pulmonary valve and ultimately create dysplastic changes in the pulmonary valve leaflets. This is particularly devastating when PAB is performed as preparation for an arterial switch procedure because the pulmonary valve becomes the neo-aortic valve after the arterial switch procedure. In addition, proximal placement of the band can lead to obstruction of coronary blood flow by direct impingement, usually of the circumflex coronary artery. Anomalous origin of a coronary artery may increase risk of this complication.[49, 50] These complications can generally be avoided by placement of the band more than 15 mm distal to the pulmonary valve cusps. Preoperative demonstration of coronary anatomy is helpful, but intraoperative vigilance during the banding procedure should avoid these types of complications.
In patients with erosion of the band into the PA, scarring and fibrosis around the band site usually prevents the life-threatening bleeding from occurring. Hemolytic anemia and local thrombus formation have been reported. Erosion seems to occur with increased frequency when narrow banding material is used, although it can occur with any material. PA pseudoaneurysm is a rare complication of pulmonary artery banding. It may be preceded by local infection and, like band erosion, is heralded by loss of the band murmur and gradient. Imaging studies demonstrate an enlarged mediastinal shadow on chest radiography and a markedly enlarged PA on echocardiography or MRI. The diagnosis of PA pseudoaneurysm formation mandates urgent surgical intervention. Repair is performed on cardiopulmonary bypass with patch repair of the MPA. Glutaraldehyde-treated autologous pericardium is preferred to synthetic material because this condition is sometimes associated with infection.
An additional complication is an ineffectual pulmonary artery banding, either from a loose band at the original procedure or later disruption of the band or erosion of the PA. In earlier studies, ineffectual banding occurred in as many as 15-20% of patients undergoing pulmonary artery banding. The results of an ineffectual band are excessive PBF and early recurrence or continuation of congestive heart failure (CHF). In addition, pulmonary vascular disease with irreversible pulmonary hypertension may potentially develop. Loss of band murmur and recurrence of CHF after pulmonary artery banding suggests loosening or erosion of the band. Furthermore, subsequent improvement may herald the onset of pulmonary vascular disease with a decrease in left-to-right shunting. Early evaluation and close follow-up should allow revision before the onset of irreversible changes.
Outcome and Prognosis
Pulmonary artery banding (PAB) should result in improved hemodynamics and overall clinical improvement in the patient. The signs and symptoms of congestive heart failure (CHF) should resolve or become medically manageable, cardiomegaly should decrease, and pulmonary vascular resistance should decrease. Pulmonary artery banding affords protection to the pulmonary vasculature against fixed irreversible pulmonary hypertension secondary to pulmonary overcirculation and elevated pulmonary artery (PA) pressures.
The mortality rate of pulmonary artery banding is clearly associated more with the complexity of cardiac defect and overall condition of the patients than with the procedure itself. Patients who are selected for pulmonary artery banding and a staged repair are often chosen because they are considered too high risk to undergo definitive repair. Therefore, the mortality rates from earlier series have been as high as 25%. A decreasing mortality rate with pulmonary artery banding can be related to improved operative techniques, better patient selection, and timing of intervention.[56, 57, 58, 59] Additionally, improvements in anesthetic and postoperative management have also resulted in a decreased mortality rate. Current mortality rates for pulmonary artery banding are reported in some series to be as low as 3-5%.
Future and Controversies
Almost half a century since the introduction of pulmonary artery banding (PAB) by Muller and Dammann, this procedure still has a defined role in the treatment of infants who are not candidates for immediate definitive repair. In particular, it may be useful in patients with a functional single ventricle not amenable to early repair and in whom a future Fontan procedure is planned. It may also benefit patients with excessive pulmonary blood flow who are considered too ill to undergo complete repair of their cardiac defect. Interestingly, the original technique of an incisional band as described by Muller and Dammann has resurfaced as a desirable technique in some patients.
The adjustable band technique has proved useful and safe for most patients. Interest has been shown for the development of an intraluminal technique for pulmonary artery banding using circular patches of fenestrated material. This requires a cardiopulmonary bypass to perform and is therefore limited in its applicability to most patients. Ongoing research to develop a percutaneously adjustable, thoracoscopically implantable, pulmonary artery band is underway.
Additionally, research is being conducted in animals to develop a hydraulic main pulmonary artery (MPA) constrictor as an adjustable pulmonary artery banding. These types of devices would benefit patients who require multiple adjustments of a PAB for left ventricle (LV) training. An implantable device for pulmonary artery banding with telemetric control, FloWatch-R-PAB (Endoart SA, Lausanne, Switzerland) has emerged from animal studies and is currently in clinical trials.[63, 64] Early clinical results have shown the efficacy and reliability of the device, but more data and experience are needed to define the role of this technology in PAB.
A strategy of deferring biventricular repair by the application of a pulmonary artery band may not be applicable in developing and third world conditions primarily due to lack of patient compliance. A study by Brooks et al indicates that less than 50% are eventually repaired in a reasonable time frame. Moreover, patient follow-up is unreliable. Thus, in such circumstances, consideration should be given to early definitive repair, even in perceived high-risk cases.
For most patients undergoing pulmonary artery banding, the goal of the procedure remains reduction of pulmonary blood flow (PBF) and preservation of pulmonary vessels from hypertrophy and hypertension. More recently, a new indication of preparing the LV for arterial switch in older infants and children with D-transposition of the great arteries (TGA) appears to have expanded the role of this procedure. Although some surgeons would contend that pulmonary artery banding is largely of historical interest, this technique clearly will continue to maintain a place in the therapeutic armamentarium of the congenital heart surgeon.
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