Ann Thorac Surg 2003;75:1008-1010
© 2003 The Society of Thoracic Surgeons
Case report
Pulmonary artery banding before Norwood procedure
Christian Pizarro, MDa*,
William I. Norwood, MD, PhDa
a Nemours Cardiac Center, Alfred I. duPont Hospital for Children, Wilmington, Delaware, USA
Accepted for publication September 9, 2002.
* Address reprint requests to Dr Pizarro, Nemours Cardiac Center, Alfred I. duPont Hospital for Children, 1600 Rockland Rd, Wilmington, DE 19899, USA
e-mail: cpizarro{at}nemours.org
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Abstract
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Described here is the use of bilateral pulmonary artery banding as a means to achieve effective restoration of adequate systemic blood flow before a Norwood procedure in two newborns with hypoplastic left heart syndrome who presented after birth with a severe imbalance of Qp/Qs and multiorgan system dysfunction despite usual pharmacologic and ventilatory strategies.
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Introduction
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An increasing understanding of the physiology exemplified by neonates with single ventricle and a ductus-dependent systemic circulation has led to significant progress in the perioperative management of patients with hypoplastic left heart syndrome (HLHS). Nevertheless, significant challenge still exists when these patients present after birth with significant disparity of flow to the pulmonary versus the systemic circulation, accompanied by inadequate end-organ perfusion that persists despite measures to decrease the high Qp/Qs. We describe here the use of bilateral pulmonary artery banding as a means of achieving increased systemic flow and consequential recovery of severe end-organ dysfunction before a Norwood procedure.
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Case reports
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Case 1
A 2.9-kg newborn presented with grunting and mild cyanosis. The diagnosis of HLHS (aortic atresia, mitral hypoplasia) was made, and PGE1, infusion along with mechanical ventilation were initiated before transport. On admission signs of a high Qp/Qs and low systemic perfusion were evident. Initial arterial blood gas was pH 6.59, PaCO2 15, PaO2 188, and BE –30. Laboratory findings included a serum creatinine of 2.9 mg/dL, AST 1369 IU, and ALT 300 IU. Nitrogen and CO2 were added to the inspired gas admixture, intravascular volume was repleted, and a dopamine infusion was initiated. All measures were ineffective in balancing the Qp/Qs.
Therefore, through a midline sternotomy, the right and left pulmonary arteries were individually banded. This was readily accomplished by placing a 7F wire or right-angle clamp (Codman, Randolph, MA) adjacent to the outside of the artery proximally. A ligature was tied around the artery and wire combined (Fig 1). The size of the bands was based on approximating the cross-sectional area to a 4-mm systemic-to-pulmonary artery shunt. The combined cross sectional area of two 6F orifices is 3.82 mm and 4.4 mm for a 7F size.
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Fig 1. Schematic drawing of the branch pulmonary artery banding. A tourniquet has been placed around the right pulmonary artery to allow partial control of the pulmonary blood flow while the banding is performed on the left pulmonary artery.
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Subsequently, the patient was continued on the same ventilation strategy. Shortly thereafter, signs of a Qp/Qs
1 with improved systemic perfusion became apparent. The arterial blood gas showed a pH of 7.37, PaCO2 62, PaO2 37, and BE +11. Postoperative echocardiography revealed a peak gradient across the right and left pulmonary artery bands of 60 and 52 mm Hg, respectively (Fig 2).
Renal, hepatic, and cardiac dysfunction resolved over the next few days. The patient underwent a Norwood procedure 10 days later. The postoperative course was unremarkable, and the patient went home on postoperative day 35.
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Fig 2. Postoperative echocardiogram with color (A) and continuous wave Doppler (B) showing narrowing and increased velocity across the right pulmonary artery (RPA) band.
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Case 2
A 2.8-kg newborn was transferred from overseas with diagnosis of HLHS (aortic atresia, mitral atresia). There was moderate atrioventricular valve regurgitation, and the ventricular shortening fraction was severely decreased on echocardiography. Before transport, the patient was intubated and a PGE1 infusion was instituted. Despite ventilation with 21% FiO2 there was significant imbalance of ventricular output towards the pulmonary circulation with signs of poor systemic perfusion. On admission the patient was placed on 3% inspired CO2, the FiO2 was reduced to 17% and a dopamine infusion was begun. Poor peripheral perfusion and metabolic acidosis was unrelenting. The patient was anuric, with a distended abdomen and bloody stools. Arterial blood gas was pH 7.24, PaCO2 17, PaO2 48, and BE –20. Laboratory values included serum creatinine of 2.8 mg/dL, AST 1097 IU, and ALT 200 IU. The patient underwent bilateral pulmonary artery banding. Soon afterward, there was resolution of the persistent metabolic acidemia and improvement of peripheral perfusion. However, blood cultures grew Citrobacter Fruendii, and serial abdominal films revealed extensive colonic pneumatosis. A total abdominal colectomy was performed the following day. Signs of well-balanced Qp/Qs and improved systemic perfusion were sustained, and renal and liver function test returned to normal. Subsequently, a Norwood procedure was performed 6 days after pulmonary artery banding. The remaining hospital course was uncomplicated, and the patient was discharged home on postoperative day 20.
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Comment
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After considerable experience and a better understanding of the physiology present in newborns with HLHS, preoperative management of these patients has improved that generally achieves circulatory stability and good end-organ perfusion in preparation for surgical palliation. The critical role played by the balance between systemic and pulmonary circulation in newborns with HLHS has long been recognized, and several strategies have been developed to achieve this goal. The usual maneuvers generally include the use of PGE1 infusion and measures to balance pulmonary to systemic resistance ratio including the use of inspired hypoxic admixture, carbon dioxide and judicious use of inotropic agents or vasodilators [1, 2]. In some cases, however, a severe imbalance of Qp/Qs and consequential multiorgan system dysfunction ensues before surgical intervention, raising concern of the added impairment from cardiopulmonary bypass and a period of circulatory arrest. Moreover, in this scenario, pharmacologic and ventilatory maneuvers often prove insufficient because of combined hypotension and markedly elevated systemic vascular resistance and mechanical measures are required to establish adequate systemic perfusion. In the cases presented here, bilateral branch pulmonary artery banding was performed to mechanically limit systolic pulmonary flow and diastolic runoff into the pulmonary circulation. In both cases, pharmacologic and ventilatory strategies failed to restore effective systemic flow. Shortly after pulmonary artery banding there was a significant improvement in systemic perfusion, evidenced by physical signs as well as laboratory data. In addition, this beneficial effect persisted over time, providing the necessary conditions for the recovery of organ dysfunction, and in one case allowed for a major intrabdominal procedure to be performed without significant disturbance of appropriate circulatory balance.
Placement of a tourniquet around the systemic-to-pulmonary artery shunt after the Norwood procedure has been reported to be effective in achieving a balanced Qp/Qs when other measures have failed [3]. Reduction of pulmonary blood flow by pulmonary artery banding was reported by Gibbs and colleagues [4] in a group of patients with HLHS using bilateral pulmonary artery banding, stenting of the PDA and atrial septectomy as an alternative to a Norwood procedure in newborns. However, with a similar approach we have observed intimal hyperplasia through the stent mesh, resulting in obstruction to systemic flow with insidious development of pressure load as well as volume load. In the current era, the use of extracorporeal circulatory support may seem an attractive option to resuscitate these critically ill patients. However, in addition to the deleterious effects of extracorporeal support, the excessive runoff into the pulmonary bed at the expense of systemic perfusion remains a significant problem [5].
With these considerations in mind, we elected to reduce the excessive runoff into the pulmonary vascular bed by performing a bilateral pulmonary artery banding in preparation for a Norwood procedure. This approach proved to be a simple, quick, and remarkably effective means of restoring a satisfactory systemic perfusion, providing the appropriate circulatory conditions for the recovery of multiple organ dysfunction in these 2 critically ill neonates before a Norwood procedure in the newborn period.
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References
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- Tweddell J.S., Hoffman G.M., Kessel M.W., et al. Phenoxybenzamine improves systemic oxygen delivery after the Norwood procedure. Ann Thorac Surg 1999;67:161-168.[Abstract/Free Full Text]
- Mora G.A., Pizarro C., Jacobs M.L., et al. Experimental model of single ventricle physiology: influence of carbon dioxide on pulmonary vascular dynamics. Circulation 1994;90:II43-46.
- Schmid F.X., Kampmann C., Kurocynski W., et al. Adjustable tourniquet to manipulate pulmonary blood flow after Norwood operations. Ann Thorac Surg 1999;68:2306-2309.[Abstract/Free Full Text]
- Gibbs J.L., Wren C., Watterson K.G., et al. Stenting of the arterial duct combined with banding of the pulmonary arteries and atrial septectomy or septostomy: a new approach to palliation for hypoplastic left heart syndrome. Br Heart J 1993;69:551-555.[Abstract/Free Full Text]
- Pizarro C., Davis D.A., Healy R.M., et al. Is there a role for extracorporeal life support after stage I Norwood?. Eur J Cardio-thorac Surg 2001;19:294-301.[Abstract/Free Full Text]
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Abstract
Introduction
