Ann Thorac Surg 1998;66:836-841
© 1998 The Society of Thoracic Surgeons
Original articles: Cardiovascular
Does banding the pulmonary artery affect pulmonary valve function after the Damus-Kaye-Stansel operation?
Zahid Amin, MDa,b,c,d,
Carl L. Backer, MDa,
C. Elise Duffy, MDa,b,c,d,
Constantine Mavroudis, MDa,b,c,d
a Division of Cardiovascular-Thoracic Surgery, Children’s Memorial Medical Center, Chicago, Illinois, USA
b Division of Cardiology, Children’s Memorial Medical Center, Chicago, Illinois, USA
c Department of Surgery, Northwestern University Medical School, Chicago, Illinois, USA
d Department of Pediatrics, Northwestern University Medical School, Chicago, Illinois, USA
Address reprint requests to Dr Backer, Division of Cardiovascular Surgery, Children’s Memorial Medical Center, 2300 Children’s Plaza, Box 22, Chicago, IL 60614
e-mail: (c-backer{at}nwu.edu)
Presented at the Thirty-fourth Annual Meeting of The Society of Thoracic Surgeons, New Orleans, LA, Jan 26–28, 1998.
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Abstract
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Background. The Damus-Kaye-Stansel (DKS) operation can be an effective palliation in patients who have single-ventricle physiology and systemic outflow obstruction. Pulmonary artery banding (PAB) may be used as a preliminary procedure in these patients to limit overperfusion of the pulmonary circulation. In some series, the DKS operation has been associated with pulmonary insufficiency (PI). We retrospectively analyzed medical records of our patients who had PAB and later DKS to determine the incidence of PI in these patients.
Methods. Between 1982 and 1996, 15 patients underwent PAB before DKS. Median age at PAB placement was 7 days and median duration of PAB was 7 months. Echocardiograms obtained before PAB, before DKS, and at the most recent post-DKS follow-up were reviewed.
Results. Follow-up ranged from 1 to 15 years (mean follow-up, 7.5 years). One patient had trivial PI before PAB, which progressed to moderate PI at the last follow-up. Only 1 other patient had mild PI, but only at the last follow-up after DKS.
Conclusions. These findings suggest that prior PAB does not appear to cause significant PI in patients slated for DKS, and the incidence of significant PI after the DKS operation is relatively low.
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Introduction
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The Damus-Kaye-Stansel (DKS) operation was initially described for repair of transposition of the great arteries (TGA) to avoid coronary artery translocation [1–3]. Since the original description the spectrum of anomalies for which the DKS operation is used has expanded to other complex univentricular or biventricular cardiac lesions, such as double-inlet left ventricle, tricuspid atresia with TGA {S,D,D}, Taussig-Bing malformation, and some patients with aortic arch interruption with a malalignment-type ventricular septal defect (VSD) [4–7]. The DKS operation has been associated with a high mortality in the neonatal period in some series [4, 5, 8, 9]. Pulmonary artery banding (PAB) is an attractive option in patients with overperfusion of the pulmonary circulation but it does seem to have some drawbacks. Subaortic stenosis or bulboventricular foramen narrowing occurs naturally and sometimes secondary to ventricular hypertrophy from PAB [10–13] or a change in the ventricular geometry [14]. There is always a chance of damaging the pulmonary valve with an improper PAB, thus decreasing the availability of the valve for future operations should a need arise to incorporate the valve in the systemic circulation [15]. There are some reports that suggest abandoning PAB in favor of a more aggressive Norwood-type initial procedure because of complications attributed to PAB [9, 11, 16]. Some authors have reported that pulmonary regurgitation (PR) is common after the DKS operation; this has been attributed to distortion of the valve or prior PAB [5, 8, 16, 17]. Other authors claim that the incidence of PR after incorporating the pulmonary valve in the systemic circulation is low [18]. The purpose of this report was to review the medical records of our patients and determine whether prior PAB increases the risk of PR in patients who have subsequently undergone the DKS operation.
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Material and methods
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Patients
From 1982 through 1996, 15 patients had a DKS operation after initial PAB. All patients who had the DKS operation as the primary procedure were excluded. The medical records of these patients were reviewed. Particular attention was paid to preoperative echocardiograms, operative procedure, and postoperative echocardiogram at the most recent follow-up. There were 10 male and 5 female patients. The diagnosis included double-inlet left ventricle (n = 6), TGA with VSD (n = 4), Taussig-Bing anomaly (n = 2), tricuspid atresia (n = 2), and corrected TGA (n = 1). All associated cardiac anomalies are outlined in Table 1.
The median age at the time of placement of PAB was 7 days (range, 1 day to 4 months). The median duration for which the band was placed was 7 months (range, 4 to 84 months). All associated procedures are outlined in Table 1. The decision to take down the PAB was based on multiple factors: increasing cyanosis, increase in band pressure gradient, age appropriate for Fontan, and increase in pressure gradient across subaortic area. The band pressure gradient before taking down the band was also measured.
Echocardiography
Echocardiograms obtained before the PAB, before the DKS operation, and at the most recent follow-up after DKS were reviewed. The pulmonary valve, the PAB pressure gradient, the main pulmonary artery to aorta anastomosis, and the subpulmonary area were analyzed from subcostal and parasternal windows. Pulmonary regurgitation was classified as mild if the jet width divided by the width of the immediate subpulmonary valve region was less than 0.4, moderate if between 0.4 and 0.6, and severe if more than 0.6 [18]. The subaortic pressure gradient was obtained from the first echocardiogram and before taking down the PAB. It was defined as mild (<20 mm Hg), moderate (20 to 40 mm Hg), or severe (>40 mm Hg).
Operative technique
Pulmonary artery banding
The PAB was performed either through a median sternotomy (n = 5) or left thoracotomy (n = 10) concomitant with repair of coarctation (n = 9) or interruption of the aortic arch (n = 1). The band was placed as far away from the pulmonary valve as possible without jeopardizing the branch pulmonary arteries (PA) (Fig 1). The target distal PA pressure was half the systemic pressure with an increase in mean arterial pressure of 15 mm Hg. The band was anchored to the pulmonary trunk with two Prolene (Ethicon, Somerville, NJ) mattress sutures. All bandings were performed with a 4 mm Teflon-impregnated Dacron (n = 11) or, in our earlier experience, Mersiline (n = 4) band.
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Fig 1. (A) Placement of the pulmonary artery band away from the pulmonary valve to avoid pulmonary valve distortion. (B) Proximal placement of the pulmonary artery band will distort the pulmonary valve. (© 1998 by Rachid F. Idriss. Reprinted with permission.)
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Damus-Kaye-Stansel operation
The DKS operation was performed using bicaval hypothermic cardiopulmonary bypass in 13 patients and circulatory arrest in 2 patients. The ascending aorta was cannulated close to the innominate artery. The aorta was cross-clamped immediately proximal to the innominate artery to provide perfusion to the arch vessels during the repair. Cardioplegic solution was introduced through the aortic root. Topical myocardial cooling was also used. The main PA was transected at the site of the PAB. The initial incision on the medial aspect of the aorta was begun just above the commissural posts of the aortic valve. The approximate length of the aortic opening was equal to the diameter of the pulmonary trunk. It is critical to avoid distortion of the proximal pulmonary trunk and aorta as this will result in pulmonary valve regurgitation. In 14 of 15 patients, the DKS operation was facilitated by the use of a prosthetic patch. A triangular-shaped patch of expanded polytetrafluoroethylene (W. L. Gore, Flagstaff, AZ) was used in 8 patients, a Hemashield patch (Hemashield microvel double velour graft; Meadox Medicals, Inc, Oakland, NJ) in 4 patients, and a pulmonary homograft in 2 patients was used as a hood for the DKS procedure (Fig 2A). The hood technique facilitates construction of a tension-free anastomosis with no distortion of the pulmonary valve or coronary arteries. In only 1 patient was a direct main PA to ascending aorta anastomosis constructed. This may distort the pulmonary trunk, cause tension on the pulmonary valve, and result in pulmonary valve regurgitation (Fig 2B).
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Fig 2. (A) The Damus-Kaye-Stansel operation constructed with the hood technique keeps the pulmonary trunk free of distortion and tension on the valve. (B) The Damus-Kaye-Stansel operation constructed without the hood may cause tension on the valve and distortion of the trunk and the valve with resultant valve regurgitation. (© 1998 by Rachid F. Idriss. Reprinted with permission.)
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Results
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There was no operative mortality during either PAB or DKS operation. There was one late death with resultant overall mortality of 6.7% (95% confidence interval [CI], 0.017 to 0.32). This patient had corrected transposition with subaortic stenosis and had a prior systemic to PA shunt in addition to a Glenn procedure because of low oxygen saturations. He died 2 months after the DKS operation of unrecognized conduit obstruction.
The Kaplan-Meier estimate of freedom from pulmonary insufficiency after PAB and later DKS is shown in Fig 3. The prevalence of pulmonary insufficiency as of the last follow-up is 13% (95% CI, 0.017 to 0.405). On the initial pre-PAB echocardiograms, trivial PR was present in 1 patient. The PR progressed to mild by echocardiogram obtained before taking down the PAB in the same patient and to moderate PR at the most recent follow-up. This patient had the PAB placed for 84 months and was temporarily lost to follow-up primarily because of the parent’s reluctance to permit an operation. Mild PR had developed in 1 other patient at the last follow-up. This patient had his PAB placed at another institution. At the time of band take down, the band was found abutting the pulmonary valve leaflets, causing mild adhesions (which had to be separated) between the leaflets. There was no PR in the remaining patients at the last follow-up by echocardiogram or by physical exam. The PAB pressure gradient before the take down ranged from 35 mm Hg to 100 mm Hg (mean, 47 mm Hg).
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Fig 3. Kaplan-Meier curve of freedom from pulmonary valve insufficiency after pulmonary artery banding followed by Damus-Kaye-Stansel operation.
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Interestingly, 4 patients in our series had aortic valve regurgitation, 1 patient with Taussig-Bing anomaly, 2 with TGA, and 1 patient with double-inlet left ventricle. Three of them required closure of the aortic valve. The remaining patient has mild aortic regurgitation and remains stable. Four patients in this series had complete heart block, 2 during the initial DKS and 2 after revision of a Fontan operation. The incidence of atrial arrhythmia after completion to Fontan in this group was almost 40% (3 of 8). Two patients have undergone Fontan conversion to extracardiac Fontan, with intraoperative cryoablation guided by electrophysiologic mapping of the tachycardia circuit.
A mild VSD or bulboventricular pressure gradient was present in 2 patients before the PAB and developed in 2 patients subsequent to the PAB placement. Of the 2 patients who had a VSD pressure gradient after the PAB, one had PAB placement at an outside institution. At the time of DKS operation the PAB pressure gradient was 80 to 100 mm Hg, and the VSD pressure gradient was 35 mm Hg. The other patient had the band placed for 84 months, his PAB pressure gradient was 90 mm Hg, and the VSD pressure gradient was 20 mm Hg. Follow-up ranged from 2 to 15 years (mean, 7.5 years). Three patients were lost to follow-up after 5, 6, and 7 years, respectively.
We believe that 2 patients had PAB-related complications. One patient had bilateral branch PA stenosis and the other patient had atrioventricular valve regurgitation. The first patient required pulmonary angioplasty at the time of modified Fontan and the other had a DeVega valvuloplasty at the time of DKS operation.
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Comment
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The recent trend toward early primary DKS operation is appealing and saves that patient from multiple operations [19]. However, there are several reports in which primary DKS operation was associated with a high mortality [5, 9, 20] (Table 2). This is balanced by more recent reports showing a considerable improvement in survival with primary DKS operation [19, 21]. The purpose of this review is not to support a staged approach with PAB for all patients with single-ventricle morphology and subaortic obstruction, but rather to demonstrate that in selected patients PAB is not necessarily to be condemned as always leading to PR. In fact, PAB in single-ventricle physiology is a very controversial issue and there are numerous articles in the literature for and against this procedure [4, 17, 19–21].
The fate of the pulmonary valve in the systemic circulation in the context of several other different procedures appears to be satisfactory. Pulmonary valve function after arterial switch, Norwood-type repair, and the Ross procedure has been durable with a very low incidence of valve regurgitation [23]. On the other hand, the incidence of PR after DKS operation has been significant in certain series [5, 8, 17]. The main cause is thought to be distortion of the pulmonary trunk by the DKS and the prior PAB. Additionally, there are the other PAB-related complications like ventricular hypertrophy [24], increase in outflow tract gradient, atrioventricular valve regurgitation [16], and diastolic dysfunction [20]; all of these subsequently may have an impact on Fontan survival [25]. However our experience suggests that a PAB performed meticulously without encroachment on the pulmonary valve can be successfully used as a short-term palliation in selected patients. Surgeons recommending PAB as an initial palliation for these patients need to emphasize that the DKS operation should be undertaken sooner rather than later (4 to 8 months after PAB) [12, 17].
We believe that there is a subset of patients who can benefit from a PAB rather than a primary DKS operation without affecting the ultimate survival and function of the pulmonary valve. The final decision as to the type of operation depends on the surgeon and the individual institutional experience. The advantage of the thoracotomy approach is that there are minimal adhesions to deal with at the time of DKS. In addition, this is our standard approach to coarctation repair (without cardiopulmonary bypass), which was required in 9 of 10 patients who had a thoracotomy. The sternotomy approach is our preference, however, if arch repair is not needed as it allows for more precise band placement and anchoring.
Although 6 patients in this series had a form of TGA with ventricular septal defect treated by DKS and right ventricular-to-pulmonary artery conduit, since 1990 all patients with Taussig-Bing anomaly or complex TGA have undergone either arterial switch operation or Kawashima repair [26]. These patients are no longer considered candidates for a DKS and most have complete repair in the neonatal period.
In our experience, we believe that the use of a hood of Gore-tex or homograft in completing the anastomosis of the DKS operation has helped prevent late pulmonary valve regurgitation. Without the hood the wall of the pulmonary trunk away from the aorta is under traction, which can distort the pulmonary trunk and hence the pulmonary valve (Fig 2B). We speculate that this contributed to post-DKS PR. In addition, the impact of the ejection jet on one side of the valve (caused by pulmonary valve distortion) may cause turbulent flow in the pulmonary trunk that further increases regurgitation with passage of time. The Kaplan-Meier estimate of freedom from pulmonary insufficiency at 8 years after DKS in our patients was 0.75. In all univentricular connections with restrictive ventricular septal defects, the pulmonary valve is essentially the "good" systemic valve. In our opinion these valves can be used as part of the eventual repair. Other authors have described modifications of the original DKS procedure that minimize tension on the anastomosis [7, 27].
In conclusion, we have demonstrated that in selected patients PAB followed by DKS does not necessarily result in pulmonary valve regurgitation. We feel that PAB is a safe and effective means of palliation for many infants with single ventricle and heart failure secondary to unobstructed pulmonary blood flow. The initial PAB should be placed distal enough to not abut the pulmonary valve, and DKS should be constructed with a prosthetic hood to prevent pulmonary valve distortion.
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References
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Abstract
Introduction
