Ann Thorac Surg 2001;71:361-362
© 2001 The Society of Thoracic Surgeons
Invited commentary: case report
Invited commentary
P. Syamasundar Rao, MDa
a Division of Pediatric Cardiology, Saint Louis University School of Medicine, Cardinal Glennon Children’s Hospital, 1465 S Grand Blvd, St. Louis, MO 63104, USA
Bonnet and colleagues describe an infant with tricuspid atresia with normally related great arteries and a large ventricular septal defect (VSD) in whom they performed banding of the pulmonary artery with an absorbable polydiaxanone ribbon [1]. Band material has spontaneously resorbed by 5 months, whereas the VSD became restrictive. The infant underwent successful bidirectional Glenn procedure at 1 year of age. They go on to suggest that pulmonary artery banding with an absorbable material should be included among surgical options to be considered in the management of such patients.
Bonnet’s concept is ingenious and should receive serious consideration. The concept is predicated on the assumption that the VSD will undergo spontaneous closure and on the hypothesis that the banded pulmonary artery initially decreases pulmonary blood flow and pressure, but will not remain stenotic after resorption of the band material. Spontaneous closure of the VSD in tricuspid atresia is well documented in the literature [2–5], and as the they predicted, such "closure" did take place in their patient. Control of signs of heart failure and development of high Doppler flow velocities across the right ventricular outflow tract suggest that banding accomplished the initial objective of decreasing the pulmonary artery pressure. Scarring, distortion, and narrowing of the banded pulmonary artery is expected after the band has been in place for several months. However, their data (Fig 1, bottom) suggest that there is indeed a widely patent undistorted pulmonary artery following spontaneous resorption of the band, although this is based on observations in a single patient. Thus, it appears that the Bonnet’s concept is valid.
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Fig 1. (Top) Successive subcostal echocardiographic views of the ventricular septal defect and of the pulmonary artery. (Left) Note the large ventricular septal defect and the normal pulmonary artery. (Middle) Two months after the pulmonary artery banding. (Right) Just before complete resorption of the banding; note the reduction of the ventricular septal defect size. (Bottom) Angiography after complete resorption. Note the absence of pulmonary artery distortion.
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Most patients with tricuspid atresia have pulmonary oligemia. A smaller proportion of patients would have pulmonary plethora. The majority of patients with increased pulmonary blood flow would belong to the transposition (discordant ventriculoarterial connection) group with a large VSD, and extremely few patients would belong to normally related great arteries (concordant ventriculoarterial connection) group, also with a large VSD [6]. In the latter group of patients, the recommendation is to institute aggressive anticongestive measures and not perform banding of the pulmonary artery because of anticipated spontaneous VSD closure [6, 7]. It has been suggested that pulmonary artery banding may be considered if there is not adequate relief of symptoms despite optimal anticongestive therapy and some time delay. Because of concern for development of pulmonary vascular obstructive disease, careful follow-up with periodic assessment of pulmonary artery pressure was recommended [6, 7]. Conventional banding of the pulmonary artery with nonabsorbable material would control the heart failure and reduce the pulmonary artery pressure without the concern for development of pulmonary vascular obstructive disease. However, as Bennet and colleagues stated, this might require earlier reintervention because the band-induced pulmonary stenosis is additive to pulmonary oligemia produced by spontaneous VSD closure. On the other hand, absorbable band may achieve both the objectives, namely control of heart failure and decrease in pulmonary artery pressure initially and no pulmonary artery stenosis as the VSD begins to close. However, the clinical application of the concept will be in only a limited number of single ventricle physiology patients in whom the combination of normally related great arteries and large VSD coexist.
References
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Bonnet D., Sidi D., Vouhé P.R. Absorbable pulmonary artery banding in tricuspid atresia. Ann Thorac Surg 2001;71:360-361.[Abstract/Free Full Text]
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Rao P.S. Natural history of the ventricular septal defect in tricuspid atresia and its surgical implications. Br Heart J 1977;39:276-288.[Abstract/Free Full Text]
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Sauer U., Hall D. Spontaneous closure or critical decrease in the size of the ventricular septal defect in tricuspid atresia with normally related great arteries: surgical implications. Herz 1980;5:369-384.
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Rao P.S. Further observations on the spontaneous closure of physiologically advantageous ventricular septal defect in tricuspid atresia: surgical implication. Ann Thorac Surg 1983;35:121-131.[Abstract]
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Rao P.S. Natural history of ventricular septal defects in tricuspid atresia. In: Rao P.S., ed. Tricuspid atresia. Mount Kisco, NY: Futura Publishing Co, 1992:261-293.
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Rao P.S. Tricuspid atresia. In: Moller J.H., Hoffman J.I.E., eds. Pediatric cardiovascular medicine. New York: Churchill Livingstone, 2000:421-441.
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Rao P.S., Covitz W., Chopra P.S. Principles of palliative management of patients with tricuspid atresia. In: Rao P.S., ed. Tricuspid atresia. Mount Kisco, NY: Future Publishing Co, 1992:297-320.
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