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Ann Thorac Surg 2002;74:1219-1224
© 2002 The Society of Thoracic Surgeons

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Original article: cardiovascular

Mortality of pulmonary artery banding in the current era: recent mortality of PA banding

^a Cardiothoracic Surgery, Tokyo University Hospital, Tokyo, Japan
^b Division of Cardiovascular Surgery and Pediatric Cardiology, National Children’s Hospital, Tokyo, Japan

* Address reprint requests to Dr Takayama, Department of Cardiothoracic Surgery, Tokyo University Hospital, 7-3-1 Hongo, Bunkyo-ku, Tokyo 113-8655, Japan.
e-mail: hirofu2{at}hotmail.com

Presented at the Thirty-eighth Annual Meeting of The Society of Thoracic Surgeons, Fort Lauderdale, FL, Jan 28–30, 2002.

	Abstract

Top Abstract Introduction Patients and methods Results Comment Acknowledgments Discussion References

 
BACKGROUND: The mortality of pulmonary artery banding improved significantly in the 1980s. However, we lack information on this procedure in the current era.

METHODS: The results of pulmonary artery banding in 365 patients who had operations between 1966 and 2001 were reviewed. The patients were divided into three groups: (1) group 1 patients who had operations between 1966 and 1979, (2) group 2 patients who had operations between 1980 and 1989, and (3) group 3 patients who had operations between 1990 and 2001.

RESULTS: Significantly younger and smaller patients have been operated on recently (mean age: group 1, 169.0 ± 40 days; group 2, 101.8 ± 11 days; and group 3, 69.7 ± 8.9 days; and mean weight: 4.6 ± 0.1, 4.1 ± 0.1, and 3.2 ± 0.1 kg, respectively). A decrease was found in the number of simple cardiac anomalies, such as isolated ventricular septal defects. The early mortality in the three groups was 38.3% for group 1 (65 of 187), 13.5% for group 2 (15 of 111), and 13.8% for group 3 (12 of 87). Although the mortality did not vary significantly between groups 2 and 3, it improved over time in patients weighing less than 3 kg. Multivariate analysis of group 3 demonstrated that no isolated variable, including sex, weight, and diagnosis was a significant risk factor.

CONCLUSIONS: Despite the advances in perioperative management, we found no improvement in the early mortality of pulmonary artery banding during the last decade. These results will support the preference for primary repair of intracardiac anomalies in small infants. However, this operation can now be performed with the same risk even in smaller patients. We believe that pulmonary artery banding has a role in the treatment of congenital cardiac anomalies.

	Introduction

Top Abstract Introduction Patients and methods Results Comment Acknowledgments Discussion References

 
Muller and Dammann [1] introduced pulmonary artery (PA) banding in clinical practice in 1951. Since then, this operation has been used as a palliative procedure for small infants with congenital heart defects, to be followed by definitive repair at an older age. The technical difficulty involved in primary repair and concerns regarding the use of cardiopulmonary bypass in small infants led many institutions to favor this staged approach. However, the perioperative morbidity and mortality of early primary repair has significantly improved in recent years. Many neonates and infants are now treated by primary repair with good results, and PA banding is selected as the initial operative procedure in fewer patients. However, this operation still remains the procedure of choice for a diagnostic subset of patients.

The mortality of PA banding improved dramatically in the 1980s. The reported mortality rate decreased from approximately 30% before 1980 to approximately 10% during the 1980s [2–6]. With advances in cardiac operations, the results of PA banding should have improved further in the 1990s. However, there are no data to support such an assumption, partly because PA banding has a smaller role now in the surgical treatment of congenital cardiac defects.

PA banding has been performed at the National Children’s Hospital, Tokyo, since 1966. In the present study, we review our 36-year experience with PA banding to describe the current results and risks of the operation.

	Patients and methods

Top Abstract Introduction Patients and methods Results Comment Acknowledgments Discussion References

 
Patient population
From March 1966 through May 2001, 365 patients underwent PA banding at the National Children’s Hospital, Tokyo. The clinic and hospital records of these patients were retrospectively reviewed.

The patients were divided into three groups: (1) group 1 (n = 167), patients who had operations between 1966 and 1979; (2) group 2 (n = 111), patients who had operations between 1980 and 1989; and group 3 (n = 87), patients who had operations between 1990 and 2001. For each patient, the preoperative demographics and outcome of the banding operation were recorded.

Surgical procedure
A standard surgical technique was used for most of the patients. The pulmonary artery was approached through a median sternotomy or lateral thoracotomy. In patients with a ductus arteriosus, coarctation, or an interrupted arch present, posterolateral thoracotomy was performed. A tape was placed around the pulmonary artery just above the sinus of the pulmonary valve. The band material preferred in more recent operations has been polytetrafluoroethylene. The circumference of the band in millimeters was set equal to the child’s weight in kilograms plus 20. This formula is a modification of that suggested by Trusler and Mustard [7]. This circumference was used as a starting point for the banding; additional adjustments to the band were made based on measurements of the pulmonary artery pressure distal to the band. The pulmonary artery pressure was reduced to one-third of the systemic blood pressure. Then the band was secured to the adventitia to prevent its migration to the distal pulmonary artery.

Statistical analysis
Statistical analyses were performed using the SPSS software (SPSS Inc, Chicago, IL). The reported p values were based on the Bonferroni–Dunn test, and multivariate analysis was performed using logistic regression.

	Results

Top Abstract Introduction Patients and methods Results Comment Acknowledgments Discussion References

 
The age and weight of the patients in all the groups ranged from 1 day to 18.3 years, and from 1.2 to 11.5 kg, respectively. Significantly younger and smaller patients have been operated on recently; the mean age at operation of each group was 169.0 ± 40, 101.8 ± 11, and 69.7 ± 8.9 days, respectively, and the mean weight was 4.6 ± 0.1, 4.1 ± 0.1, and 3.2 ± 0.1 kg, respectively (Table 1).

View larger version (21K): [in this window] [in a new window]   Fig 1. Influence of weights on early mortality.

View larger version (21K): [in this window] [in a new window]   Fig 2. Influence of diagnostic groups on early mortality.

	Comment

Top Abstract Introduction Patients and methods Results Comment Acknowledgments Discussion References

Primary repair is expected to replace staged operation, because the latter is associated with risks and there is a high probability of death in the interval before subsequent repair. The complications of banding include erosion of the band into the pulmonary arterial lumen, distal migration with obstruction of the right or left pulmonary arteries, and pulmonary insufficiency secondary to dilation of the pulmonary annulus. Another concern in neonate patients with double-inlet left ventricle with minimal or no obstruction of the bulboventricular foramen and unrestricted pulmonary blood flow, is that PA banding may hasten the development of subaortic obstruction by reducing the ventricular volume and inducing progressive ventricular hypertrophy [9].

The results of PA banding improved dramatically in the 1980s. However, no additional data are available. In the present study, with the recent advances in cardiac operations, we expected improved results with the PA banding procedure. The overall risk of PA banding in this series fell from 38.3% during the period from 1966 to 1979 to 13.5% during the period from 1980 to 1989. These results are consistent with the results of the previous studies [2–6]. However, the mortality during the period from 1990 to 2001 remained at 13.8%, not significantly different from the results in the 1980s. A comparison of group 2 with group 3 by diagnostic subgroups revealed no improvement in the survival during the 22 years. However, analysis of the demographic data of the patients in these two groups demonstrated that smaller patients who had more recent operations had significantly better outcomes.

Currently, early primary repair is the treatment of first choice for congenital cardiac defects. Palliative operations play a smaller role and are indicated in fewer patients. Isolated ventricular septal defect has been treated by primary repair with a very low operative mortality rate. However, we still prefer to perform PA banding for patients with multiple or apical muscular ventricular septal defects, and also for patients with ventricular septal defect with complex extra cardiac congenital anomalies. In our series, during the latter 22 years, ventricular septal defects, including multiple ones, were safely operated on with an early mortality of 1.7%.

Some groups advocate early primary correction of atrioventricular septal defects [10]. Günther and colleagues [11] reported that the operative mortality in patients who underwent primary repair decreased from 17.6% (during 1974 to 1979) to 5.0% (during 1990 to 1995), despite an increase in the number of patients younger than 6 months. However, they also identified patients who were younger than 6 months old as an incremental risk factor. The mortality among these young patients was 18.2%. In our study the mortality of patients with atrioventricular septal defects was 6%. Although survivors of banding still have an increased risk of death in the interval before subsequent repair, we believe that PA banding has some advantages for these diagnostic groups of patients, especially in those with very low weight, atrioventricular valve abnormality, and unbalanced ventricles.

The particular problem of aortic coarctation associated with ventricular septal defect has been dealt with differently in recent years. It has been proposed that the coarctation alone be repaired without PA banding, and that the ventricular septal defect be closed in a second operation or be allowed to close spontaneously [12]. Even one-stage repair has been advocated recently [13]. Haas and colleagues [13] documented their results of primary repair of aortic arch obstruction with ventricular septal defect in pre-term and low birth weight infants. They concluded that early repair was associated with good results. The overall hospital mortality rate was 14% (3 of 21). PA banding for the diagnostic group 3 patients was associated with a remarkably high early mortality rate of 25%. Most of the deaths were related to residual obstructive lesions of the left ventricular outflow tract or the aorta, which led to congestive heart failure.

The present approach in specialized centers is to perform complete repair during infancy for patients with such anomalies as transposition of the great arteries with ventricular septal defect, double-outlet right ventricle with subaortic ventricular septal defect, or truncus arteriosus [14]. However, other groups have not had similar success [15–16]. Analysis of our patients during the more recent 22-year period demonstrated that 4 of the 28 patients in these diagnostic groups died early after banding. Transposition of the great arteries with ventricular septal defect should be treated by a primary arterial switch operation, which is associated with better early and late outcomes. Appropriate PA banding for truncus arteriosus is difficult because of the unique character of the malformation; the procedure has been associated with a high morbidity and mortality and has not been conducted recently.

The majority of patients with single ventricle physiology with excessive pulmonary blood flow, who are eventually candidates for a Fontan-type operation, should be initially treated by PA banding. We demonstrated that the results of banding in this category of patients have improved recently. Only 2 of the 14 patients died after banding during the more recent 22 years.

Another important indication for this operation is morphologic left ventricular retraining in patients with transposition of the great arteries, in patients with prior atrial switch operation with transposition of the great arteries, and in patients with congenitally collected transposition of the great arteries. This is a relatively new indication that has recently become the focus of our attention [17].

Twelve of the 87 patients in group 3 died after banding. In the other groups, low weight at operation did not increase the risk of early death. Most deaths were related to sepsis or congestive heart failure. Some of the deaths could be attributed to concomitant extracardiac anomalies or chromosomal abnormalities. However, the rest of the deaths were related to the procedure itself. The congestive heart failure may have been caused by residual obstructive lesions in the left ventricle or the aorta, or by inadequate tightness of the band. To decrease the mortality, we need careful management of extracardiac anomalies in the patients, complete repair of obstructive lesions in the left heart system, and modification of the procedure.

The circumference of the band was mainly determined using the modified Trusler and Mustard’s [7] formula, and it was adjusted according to the pulmonary artery pressure as previously described. However, measurements of the pulmonary artery pressure were carried out in an anesthetized and mechanically ventilated patient with an open chest, and the physiology was clearly quite different from that in an awake and spontaneously breathing child. In fact, the intraoperative PA pressure decreased to approximately a third of the systemic pressure in most patients. Some modification, such as the development of an adjustable band, would be needed to achieve appropriate tightness of the band [18–19].

Our study had some limitations. First it was a retrospective study, whereas, a prospective study comparing primary repair and staged repair using PA banding would be ideal. Second, because many patients in groups 1 and 2 were lost to follow-up after the banding operation, the long-term morbidity and mortality could not be addressed.

In conclusion, despite the recent advances in cardiac operations, we found no improvement in the early mortality of PA banding. PA banding as a measure for left ventricular retraining is the procedure of choice for a selected subset of patients. As for conventional indications, early primary repair may be more beneficial. However, PA banding could be performed even in small neonates with an early mortality rate around 10%. We believe that PA banding still has some role in the treatment of congenital cardiac anomalies.

	Acknowledgments

Top Abstract Introduction Patients and methods Results Comment Acknowledgments Discussion References

 
The authors appreciate the assistance of Hideo Yasunaga, MD, PhD, with statistical analysis.

	Discussion

Top Abstract Introduction Patients and methods Results Comment Acknowledgments Discussion References

 
DR JEFFREY M. PEARL (Cincinnati, OH): It is a real nice series, and I think it confirms most of our opinion of trying to avoid bands whenever possible, that the mortality is still higher than most of the primary repairs. My question is: Do you have any information on the incidence of pulmonary artery (PA) stenosis or valve damage with the PA bands?

DR TAKAYAMA: As I discussed in the slides, we just focused on the early mortality of this procedure, so such data was not collected this time.

DR JOHN W. BROWN (Indianapolis, IN): I would be interested in your technique of pulmonary artery banding. Half of your mortality was due to congestive heart failure, which would indicate to me that your band was not tight enough. And since 24 of your patients were 2.5 kg or less, I would be very interested in how tight you placed the pulmonary artery band and exactly how you adjust it at the time of operation.

DR TAKAYAMA: We determined the tightness of the band initially based on Trusler’s rule, which is almost equal to 20-plus body weight. We adjusted the band under the PA pressure measured in the perioperative theater. The PA pressure was decreased below a third of systemic pressure.

DR FRANK A. PIGULA (Pittsburgh, PA): This is related somewhat to Dr Brown’s question in that much of the mortality was found in children who had associated lesions either coarctation or an interrupted aortic arch. Was the strategy to repair the coarctations first and come back and put a band on, or were they performed at the same time? If so, was there any residual left-sided lesions that contributed?

DR TAKAYAMA: It is very difficult to decide whether the coarctation with ventricular septal defect should be repaired primarily or if we should choose the banding operation. However we have no such data on that question.

DR MARSHALL L. JACOBS (Philadelphia, PA): A lot of people recently, perhaps most notably Dr Hanley and his associates, have advanced a very strong case for complete reparative surgery in babies regardless of small size. Noting that there was such a large number of very small babies in your recent series, and as Dr Brown pointed out, that the mortality for that group was appreciable, was small size during the period of this study a relative indication for palliation by means of banding rather than proceeding to complete repair? Also, How does the outcome of this study impact your future plans with regard to very small babies?

DR JOHN E. MAYER (Boston, MA): If I may have the privilege of the floor for one second, I thought the most interesting thing, just reading the abstract, was that the mortality for banding single ventricles was approximately equivalent to banding patients with potentially 2-ventricle repairable lesions. I think the point worth emphasizing is that palliated circulations are clearly inferior to repaired circulations. Certainly our institutional prejudice, and that of several other institutions, has been, whenever possible, to carry out a 2-ventricle repair, regardless of size or weight of the patient, whenever the anatomy allows you to do so. This would certainly fit with your conclusions, and hopefully this is an important message for all of us who are dealing with patients with congenital heart disease, particularly little babies.

DR CONSTANTINE MAVROUDIS (Chicago, IL): I am not sure that you noted how many of your patients may have had subaortic stenosis or after the band, of course, double outlet obstruction. Could you give us some information about this issue? This also speaks to John’s idea that you had some patients who died of congestive heart failure after a pulmonary artery band. It would not make sense unless, of course, there was either recognized or unrecognized subaortic stenosis. This is another thing that we have to keep in mind when we are palliating these patients.

	References

Top Abstract Introduction Patients and methods Results Comment Acknowledgments Discussion References

 

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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): Hiroo Takayama Akihiko Sekiguchi Shinichi Takamoto Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Takayama, H. Articles by Takamoto, S. Search for Related Content PubMed PubMed Citation Articles by Takayama, H. Articles by Takamoto, S. Related Collections Congenital - acyanotic