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Department of Cardiac Surgery, Alder Hey Children Hospital, Eaton Rd, Liverpool L12 2AP, United Kingdom
(Email: antonio.corno{at}rlc.nhs.uk).
Talwar and colleagues [1] report the follow-up of a technique for adjustable pulmonary artery banding (PAB) [2], which is a timely and important topic particularly because of several controversial issues.
There is an evident contrast between the general opinion that PAB is almost an abandoned procedure (at least in Western countries) and the data collected in the official North American and European database. The total number of PAB procedures reported in The Society of Thoracic Surgery (STS) congenital database was 739 for the period from 2002 to 2005, corresponding to 1.9% of the total surgical procedures (739 of 38,431); whereas the total number of PAB procedures reported in the European Association Cardio-Thoracic Surgery (EACTS) congenital database was 711, corresponding to 2.0% of the total surgical procedures (711 of 35,575). These figures contrast with the opinion that PAB is an abandoned procedure.
Another frequent disagreement is the indication for PAB, generally only considered as preparation for a univentricular type of repair or rarely for left ventricular retraining. In The STS congenital database for the 711 of 739 procedures with a diagnosis where it was identifiable, the indication for PAB in 28 cases was diagnosed as "missing" or "miscellanea", in 400 procedures (ie, 400 of 711; 56%) the indication was in view of bi-ventricular types of repair, in 276 procedures (ie, 276 of 711; 39%) it was for univentricular types of repair, and in 35 (ie, 35 of 711; 5%) it was for left ventricular re-training. Recent reports confirm the use of PAB for ventricular septal defects associated with aortic arch hypoplasia or interruption, but also for more controversial situations like multiple ventricular septal defects and complete atrioventricular septal defects. In the last two groups of malformations, the two-stage approach with PAB is considered for patients coming to surgery after long periods with malnutrition, infections, and mechanical ventilation, particularly in the presence of advanced pulmonary hypertension, as a lower risk alternative to the primary repair. The indication for PAB has also been accepted as an alternative surgical option in transposition of the great arteries with late referral and congenitally corrected transposition of the great arteries in which left ventricular re-training is required, and hypoplastic left heart malformations as a rescue procedure in critically ill neonates or as an elective procedure in preparation for subsequent surgery (ie, either the Norwood procedure or a heart transplant).
The continued interest in adjustable PAB has also been confirmed in recent experimental [3] and clinical studies of new techniques, such as the one already proposed by Talwar and colleagues [1]. The adjustable PAB provides evident clinical advantages for conventional PAB, as demonstrated by this study [1]. Furthermore, the flexibility provided by the device for telemetrically controlled PAB (FloWatch-PAB; EndoArt, Lausanne, Switzerland) [4, 5] provides additional advantages because: (1) it eliminates the need for reoperation to adjust the PAB, not only in the early postoperative period, as for the technique of Talwar and colleagues [1], but for as many as 3 years after hospital discharge [4, 6]; (2) postoperative management is simplified and postoperative mechanical ventilation, length of stay in the intensive care unit (ICU) and in the hospital are significantly reduced, even in more compromised and difficult to manage infants, such as the ones with associated anomalies, excluded in the study of Talwar and colleagues [1]; (3) the cost of the device is more than offset by the reduction in duration of postoperative mechanical ventilation, length of stay in the ICU and in the hospital, and avoidance of any PAB-related reoperation [6]; and (4) pulmonary artery reconstruction is not required any more when intracardiac repair is undertaken [5, 6].
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  H. Holmstrom, P. G. Bjornstad, B. Smevik, and H. Lindberg Balloon dilatation of pulmonary artery banding: Norwegian experience over more than 20 years Eur. Heart J., October 9, 2009; (2009) ehp406v1. [Abstract] [Full Text] [PDF]
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