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Ann Thorac Surg 1997;64:539-541
© 1997 The Society of Thoracic Surgeons

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Case Reports

Absorbable Pulmonary Artery Band

Departments of Cardiothoracic Surgery and Paediatric Cardiology, Glenfield Hospital, Leicester, United Kingdom

Accepted for publication March 20, 1997.

	Abstract

Top Footnotes Abstract Introduction Case Reports Comment References

 
Absorbable pulmonary artery banding may be a useful method of avoiding further operation or angioplasty in patients whose underlying lesion has a natural history of resolution. We report 2 cases of absorbable pulmonary artery banding using braided Dexon. In both cases the bands functioned well initially and were completely resorbed after 2 years and 6 months, respectively.

	Introduction

Top Footnotes Abstract Introduction Case Reports Comment References

 
Absorbable pulmonary artery banding has been previously reported by a number of authors [1–5]. We report 2 further cases in which an absorbable pulmonary artery band was braided using commonly available materials at the time of operation. Absorbable pulmonary artery banding is a useful technique that can be used when high pulmonary blood flow must be limited but when the natural history of the underlying lesion is one of resolution, thereby avoiding a second open operation, and in this case also avoiding transluminal pulmonary angioplasty.

	Case Reports

Top Footnotes Abstract Introduction Case Reports Comment References

 
Patient 1
A 42-day-old baby was referred for investigation of a murmur detected at routine 24-hour examination, accompanied by difficulty in breast feeding due to dyspnea. Echocardiography showed multiple muscular ventricular septal defects ("Swiss-cheese ventricular septal defect"). Cardiac catheterization demonstrated a pulmonary-to-systemic flow ratio of 6 and pressures as follows (mm Hg): pulmonary artery, 35/15; right ventricle, 50/0; and left ventricle, 82/0. Because the baby was symptomatic with a high pulmonary-to-systemic flow ratio, we decided that pulmonary artery banding was indicated, but as the natural history of Swiss-cheese ventricular septal defect is one of resolution, an absorbable band was used to obviate the need for a second open operation.

Via a left lateral thoracotomy the pulmonary artery was exposed. Using three doubled pieces of no. 1 Dexon (Davis + Geck, Cyanamid of Great Britain Ltd) a band was braided, and frapped securely around each end with 2-0 Neurolon (Fig 1). The circumference of the band was calculated according to Trussler's rule (20 mm + 1 mm/kg body weight). The band was positioned around the midpoint of the pulmonary artery, and the ends were sewn together using 4-0 Prolene (Ethicon, Somerville, NJ). The band was then secured to the adventitia of the pulmonary artery using three interrupted 4-0 Prolene sutures equally spaced around the band. Upon application of the band the peripheral oxygen saturations decreased from 100% to the mid-80s, accompanied by an increase in systemic arterial pressure. The gradient across the band was not measured at the time of the operation. Effective constriction of the pulmonary artery was confirmed echocardiographically on postoperative day 5, when a peak blood flow velocity of 4.9 m/s was measured in the pulmonary artery.

View larger version (44K): [in this window] [in a new window]   Fig 1. . Braided Dexon band.

Patient 2
A 2-day-old boy was referred with coarctation of the aorta and a large apical ventricular septal defect. The coarctation was repaired using a subclavian flap, and the pulmonary artery was banded in the same manner as in patient 1. He initially recovered well, but angiography and angioplasty were required at 6 months of age for anastomotic stenosis. The ventricular septum was seen to be intact at this time, and there was no evidence of pulmonary artery constriction or pressure gradient on right heart catheterization.

	Comment

Top Footnotes Abstract Introduction Case Reports Comment References

 
Increased pulmonary blood flow resulting in pulmonary hypertension is a frequent problem in neonates and infants with congenital heart disease. Pulmonary artery banding is a useful palliative procedure in such situations, but can be complicated by the later development of cyanosis as the infant outgrows the band, thereby precipitating the need for a definitive correction or another palliative procedure. The use of an absorbable band circumvents this problem as the band is gradually absorbed with time so that the constriction of the pulmonary artery either resolves spontaneously or can be easily treated by balloon angioplasty.

A variety of methods have been tried to construct such an absorbable pulmonary artery band. Epstein and associates [2] evaluated a segmented silicone-coated Dacron mesh 2 to 4 mm wide, sewn together with 2-0 polydioxane sutures in a canine model. They performed successful balloon angioplasty 3 months later. Similarly Vince and colleagues [3] reported the use of a dilatable pulmonary artery band in humans. Meliones and colleagues [4] used a Vicryl band in puppies, and proved that effective right ventricular outflow tract obstruction persisted for 1 year. Moreover, such obstruction could be successfully relieved by pulmonary artery dilation. Warren and associates [1] described an absorbable band that expands in a staged fashion without any need for angioplasty. Gutierrez de Loma and colleagues [5] used 3-mm polydioxane for pulmonary artery banding in 5 infants, none of whom required pulmonary artery reconstruction at subsequent reoperation.

The persistence of measurable pulmonary artery constriction in both human and animal studies for up to 1 year is not adequately explained by the absorption of the material itself, because all the materials used, including the more slowly absorbed polydioxane, lose their tensile strength after only a few weeks, although the materials themselves may remain present in a weakened form for up to 3 months. It seems likely that the absorbable pulmonary artery band may act as a nidus for scar formation, and it is the scar tissue itself that maintains the hemodynamic effect of the band, long after the material itself has been absorbed.

In conclusion, absorbable pulmonary artery banding is an elegant solution to the problem of a child with a reversible underlying condition who nevertheless requires pulmonary artery banding, and in this case it has eliminated the need for a repeat operation. However, the rate of resolution of such a band when exposed to continued systemic pressure, as it would be when the underlying lesion does not resolve spontaneously, remains to be seen, and further laboratory work in this area is required before such a procedure can be recommended in all cases.

	Footnotes

Top Footnotes Abstract Introduction Case Reports Comment References

 
Address reprint requests to Mr Peek, ECMO Office, Glenfield Hospital, Groby Rd, Leicester, LE3 9QP, UK (e-mail: ecmo1uk{at}aol.co).

	References

Top Footnotes Abstract Introduction Case Reports Comment References

 

1. Warren TE, Heath BJ, Brand WW III. A staged expanding pulmonary artery band. Ann Thorac Surg 1992;54:240–3.[Abstract/Free Full Text]
2. Epstein ML, Duncan D, Kanter RJ, O'Brien DJ, Alexander JA. Feasibility of reversible pulmonary artery banding: early results and intermediate term follow up. Ann Thorac Surg 1990;50:94–7.[Abstract/Free Full Text]
3. Vince DJ, Culham JA, Le Blane JG. Human clinical trials of the dilatable pulmonary artery banding prosthesis. Can J Cardiol 1991;7:319–42.
4. Meliones N, Rocchini AP, Bove EL, et al. A balloon dilatable pulmonary artery band in the dog. Result at one year. J Thorac Cardiovasc Surg 1991;102:790–7.[Abstract]
5. Gutierrez de Loma J, Ferreiros Mur M, Castilla Moreno M, Garcia Pena R, Gonzalez de Vega N. Reabsorbable banding: our initial experience. Rev Esp Cardiol 1991;44:677–9.[Medline]

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This Article Abstract Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Saify S. Arsiwala Mark St.J. Hickey Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Peek, G. J. Articles by Hickey, M. St.J. Search for Related Content PubMed PubMed Citation Articles by Peek, G. J. Articles by Hickey, M. St.J.