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Ann Thorac Surg 2001;71:360-361
© 2001 The Society of Thoracic Surgeons

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Case report

Absorbable pulmonary artery banding in tricuspid atresia

^a Département de Cardiologie Pédiatrique, Hôpital Necker-Enfants Malades, Assistance Publique-Hôpitaux de Paris, Paris, France

Accepted for publication March 14, 2000.

Address reprint requests to Dr Bonnet, Service de Cardiologie Pédiatrique, Hôpital Necker-Enfants Malades, 149, rue de Sèvres 75743 Paris Cedex 15; France
e-mail: damien.bonnet{at}nck.ap-hop-paris.fr

	Abstract

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A child with tricuspid atresia, concordant ventriculoarterial connections, large ventricular septal defect, and elevated pulmonary artery pressure underwent pulmonary artery banding with a polydioxanone ribbon. This procedure was successful in this patient as the ventricular septal defect became restrictive while the banding was fully absorbed after 5 months. This technique could be included in the panel of surgical strategies for patients with single ventricle physiology and potential but insufficient subpulmonary stenosis in early infancy.

	Introduction

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Tricuspid atresia with concordant ventriculoarterial connections and elevated pulmonary artery pressure is a rare form of tricuspid atresia [1]. Spontaneous diminution in size of the ventricular septal defect occurs frequently in this defect leading to a subpulmonary stenosis [2, 3]. When this spontaneous outcome is delayed, banding the pulmonary trunk is warranted to keep the pulmonary resistances low and allow a subsequent cavopulmonary connection. This banding may dramatically accelerate the ventricular septal defect closure and these successive obstructions along the pulmonary tract may lead to a profound reduction in pulmonary blood flow when the child grows and a second palliative procedure may be urgently needed. Here, we report on a child with tricuspid atresia, concordant ventriculoarterial connections, and elevated pulmonary artery pressure in whom we banded the pulmonary artery trunk with an absorbable pulmonary band to avoid an early secondary palliation.

The patient was a full-term infant referred at birth for mild cyanosis. Cardiac examination was normal, particularly there was no heart murmur. Chest roentgenogram was normal and the electrocardiogram showed exclusive left-sided electric activity. The electrocardiogram showed left axis deviation and left ventricular hypertrophy. Echocardiography showed tricuspid atresia with concordant ventriculoarterial connections and a large ventricular septal defect (9 mm). Maximal Doppler flow velocity across the ventricular septal defect was 1.5 m/s. One month later, she had failure to thrive and echocardiography still showed a large ventricular septal defect with no increase of maximum Doppler flow velocity across the ventricular septal defect as well as left ventricular dilatation and hyperkinesia. Catheterization showed elevated pulmonary artery pressure (70/25–50 mm Hg; aortic pressure 83/66–78 mm Hg) with mild cyanosis (oxygen saturation, 87%). She underwent a pulmonary artery banding with a 5-mm band made of interlaced fibers of polydioxanone (PDS; Ethicon, Ethnor SA, Neuilly/Seine, France). The pulmonary banding was tightened until the mean pulmonary pressure decreased below 15 mm Hg. Follow-up was performed monthly. Successive echocardiograms showed an adequate position of the banding. Maximum Doppler flow velocity through the ventricular septal defect and the pulmonary artery banding was more than 4 m/s. After 4 months, the ventricular septal defect was smaller (5 mm) and the maximum Doppler flow velocity was 5.2 m/s through the pulmonary outflow tract. The resorbtion of the banding was complete after 5 months. At that time, the ventricular septal defect measured 4 mm, the Doppler flow velocity was 4.3 m/s, and the oxygen saturation was 87%. At 1 year of age, the cyanosis increased (oxygen saturation, 78%) and she underwent a second catheterization to assess her candidacy for the bidirectional Glenn. The mean pulmonary pressure was 16 mm Hg and the angiography showed no distortion of the pulmonary trunk and branches (Fig 1). She underwent a partial bidirectional Glenn without bypass and she is doing well 6 months later (oxygen saturation, 91%).

	Comment

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Total cavopulmonary connection is the usual goal of therapy for children with tricuspid atresia [4]. The management in infancy must aim to ensure survival and maintain suitability for a Fontan-type operation [5]. In tricuspid atresia with normally related great arteries, progressive closure of the ventricular septal defect is a common outcome [2, 3], but, if the ventricular septal defect remains too large for a couple of months, medial hypertrophy of the small pulmonary arteries may persist and contraindicate a cavopulmonary anastomosis [6]. On the other hand, one complication of the pulmonary artery banding is progressive cyanosis during the rapid growth phase requiring earlier than anticipated correction, which may produce a less than optimal result. We supposed that banding the pulmonary artery will promote closure of the ventricular septal defect by increasing the right ventricular mass leading to a sufficient subpulmonary stenosis after resorption of the banding. In addition, we did the banding with an absorbable band to avoid rapid cyanosis due to successive obstructions from the left ventricle to the pulmonary artery. Finally, the use of an absorbable band avoided distortion of the pulmonary arteries that may occur with usual banding [7]. These objectives were reached in our patient as she could undergo a bidirectional cavopulmonary shunt at 1 year of age without complications. We recently showed that the usual delay for resorption of a polydioxanone banding is about 5 months in a series of newborn infants in whom we used this technique for the treatment of a coarctation associated with a ventricular septal defect [8]. The limitation of this technique is the impossibility to use the Bernouilli equation to estimate the pulmonary artery pressure after the banding because of successive obstructions. Rapid closure of the ventricular septal defect could have occurred rapidly after the pulmonary artery banding and for this reason we performed a close follow-up. Despite these limitations, we believe that this technique could be included in the panel of surgical strategies for patients with single ventricle physiology and potential but insufficient subpulmonary stenosis in early infancy.

	References

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1. Rao P.S. A unified classification for tricuspid atresia. Am Heart J 1980;99:799-804.[Medline]
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3. Meng C.C. Spontaneous closure of ventricular septal defect in tricuspid atresia. J Pediatr 1969;75:697-700.[Medline]
4. Malcic I., Sauer U., Stern H., et al. The influence of pulmonary artery banding on outcome after the Fontan operation. J Thorac Cardiovasc Surg 1992;104:743-747.[Abstract]
5. Franklin R.C., Spiegelhalter D.J., Sullivan I.D., et al. Tricuspid atresia presenting in infancy. Survival and suitability for the Fontan operation. Circulation 1993;87:427-439.[Abstract/Free Full Text]
6. Yamaki S., Ajiki H., Haneda K., Takanashi Y., Ban T., Takahashi T. Pulmonary arterial changes in patients dying after a modified Fontan procedure following pulmonary artery banding. Heart Vessels 1994;9:263-268.[Medline]
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This Article Abstract Full Text (PDF) 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): Pascal R. Vouhé Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Bonnet, D. Articles by Vouhé, P. R. Search for Related Content PubMed PubMed Citation Articles by Bonnet, D. Articles by Vouhé, P. R. Related Collections Congenital - cyanotic Related Article