Ann Thorac Surg 1999;67:1813-1814
© 1999 The Society of Thoracic Surgeons
How to Do It
The incisional pulmonary artery band
Hillel Laks, MDa,
Jonah N.K. Odim, MD, PhDa,
Ali M. Sadeghi, MD, PhDa,
Vivek Allada, MDb
a Division of Cardiothoracic Surgery, UCLA Medical Center, Los Angeles, California, USA
b Division of Pediatric Cardiology, UCLA Medical Center, Los Angeles, California, USA
Accepted for publication December 21, 1998.
Address reprint requests to Dr Laks, Division of Cardiothoracic Surgery, UCLA School of Medicine, Box 951741, 10833 Le Conte Ave, Los Angeles, CA 90095-1741
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Abstract
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Occasionally early definitive repair of congenital heart disease carries prohibitive mortality, and interval pulmonary artery banding is necessary to protect the pulmonary arterial bed and improve systemic perfusion or prepare a systemic left ventricle for a later arterial switch operation. We describe our technique for effectively banding the pulmonary artery.
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Introduction
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Steady advances and improving results with early definitive repair of congenital heart malformations have limited banding the enlarged pulmonary artery for luxuriant blood flow and congestive heart failure. Muller and Dammann [1] introduced this palliative technique, before the routine use of cardiopulmonary bypass in congenital heart surgery, to combat the ravages of excessive pulmonary blood flow, pulmonary hypertension, and pulmonary vascular disease. The pulmonary artery band remains a useful technique in select clinical instances: a functional single ventricle, increased pulmonary blood flow prior to an eventual Fontan configuration, and preparation of the left ventricle in infants seen late with transposition of the great arteries.
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Technique
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The current surgical approach is governed largely by the need of concomitant procedures. For isolated pulmonary artery banding, an anterior left thoracotomy through the second or third intercostal space is appropriate. An alternative approach in girls is a cosmetic incision in the submammary crease and chest entry by way of the second interspace. A median sternotomy provides improved visualization and permits additional simultaneous procedures.
Although there are several acceptable approaches to pulmonary artery banding, the effectiveness of the band remains critical. A band placed too distally on the main pulmonary artery trunk can lead to pulmonary artery branch stenosis, whereas a more proximally sited band can lead to semilunar valve distortion and regurgitation. Over the years, we have frequently observed that a band that was adequate at the time of placement in the operating theater became too loose over the ensuing weeks and months. This can represent resorption of internal folds of the vessel wall that initially are present when a concentric and constricting band is placed (Fig 1). These acute infoldings of the pulmonary artery further decrease the cross-sectional area of the pulmonary artery. With time, however, these infoldings resorb, restoring a greater internal cross-sectional area, a greater pulmonary blood flow, and thus a "looser" pulmonary artery band.
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Fig 1. Circumferential banding of a dilated pulmonary artery can acutely lead to internal infolding of the arterial wall. Later resorption of the infoldings and remodeling of the arterial wall restore a greater internal cross-sectional area.
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We have recently modified our technique by decreasing the diameter of the pulmonary artery (incisional technique) before applying the band. A partial occluding C-clamp is applied to half of the diameter of the main pulmonary artery distal to the sinotubular junction (Fig 2). A perpendicular incision is made into the excluded portion of the artery. The deep V-shaped arteriotomy is closed with 5-0 polypropylene suture, effectively reducing the diameter of the vessel by approximately 40%. An umbilical tape 4 mm wide is placed around this groove in the main pulmonary artery, further tightened, and secured with sutures and hemoclips.
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Fig 2. Incisional pulmonary artery band yields a fixed reduction of 40% of the vessel diameter prior to application of a circumferential band.
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The band circumference is estimated using Trusler’s formula [2, 3]. Although this formula serves as a general guideline, physiologic end points are used to determine the final tightness of the band. Effective pulmonary artery banding produces a distal pulmonary artery pressure that is 30% to 50% of systemic with maintenance of systemic saturations of 85% to 90% on a fraction of inspired oxygen of 50% [4]. In the setting of single-ventricle physiology, lower oxygen saturations in the range of 70% to 79% are acceptable. If patients fail to achieve this level, the interatrial communication may be restrictive, and a septectomy or a septostomy may be necessary. An assessment of hemodynamic factors further defines an adequate pulmonary artery band: a simultaneous rise of 10 to 15 mm Hg in systemic arterial pressure is typically noted along with changes in pulmonary artery pressure and systemic oxygen saturation. Heart rate and rhythm and evaluation of cardiac output and acid-base status are helpful guidelines in judging optimal clinical status after pulmonary artery banding.
In our experience, the incisional pulmonary artery banding technique has produced a more stable band gradient and may prevent the late "loosening" phenomenon observed with previous techniques. At the time of definitive biventricular repair, the main pulmonary artery is simply reconstructed with a pericardial patch or ligated in a Fontan operation. Use of our incisional technique, with potential elimination of tissue infolding and band loosening, merits redefining Trusler’s formula for estimating band circumference.
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Comment
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The 19th-century French physician Poiseuille, who studied liquid flow in small tubes, discovered experimentally that the flow for a given pressure gradient is proportional to the fourth power of the tube radius and inversely proportional to the length of the tube and the fluid viscosity. Despite the assumptions inherent in the nature of ideal Newtonian fluids and steady laminar flow, this fundamental law takes on biological importance, as physiologic regulation of the circulation occurs when vascular smooth muscle changes the radius of the arteries and the arterioles. Almost half a century since the introduction of pulmonary artery banding by Muller and Dammann [1], this procedure still has a role, albeit limited, in the management of some infants who are not candidates for immediate definitive repair. For the majority, the goal of the procedure remains the reduction of pulmonary blood flow and the preservation of pulmonary vascular integrity. The incisional technique of pulmonary artery banding provides a consistently effective and durable band.
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References
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Muller W.H., Jr, Dammann J.F., Jr The treatment of certain congenital malformations of the heart by the creation of pulmonary stenosis to reduce pulmonary hypertension and excessive pulmonary blood flow: a preliminary report. Surg Gynecol Obstet 1952;95:213-219.[Medline]
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Trusler G.A., Mustard W.T. A method of banding the pulmonary artery for large isolated ventricular septal defect with and without transposition of the great arteries. Ann Thorac Surg 1972;13:351-355.[Medline]
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Albus R.A., Trusler G.A., Izukawa T., Williams W.G. Pulmonary artery banding. J Thorac Cardiovasc Surg 1984;88:645-653.[Abstract]
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Drinkwater D.C., Laks H. Pulmonary artery banding. In: Baue A.E., Geha A.S., Hammond G.L., eds. Glenn’s thoracic and cardiovascular surgery, 6th ed. Stamford, CT: Appleton & Lange, 1996:1085-1094.
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Abstract
Introduction
