Bilateral Pulmonary Artery Banding Research Articles

Successful staged repair for a rare type of truncus arteriosus with interruption of the aortic arch and abnormal origin of the left coronary artery

We report a successful staged repair for a quite rare combination of truncus arteriosus (TA), Van Praagh type A4, and abnormal origin of the left coronary artery (CA). Furthermore, the case was complicated by a variant of the chromosomal anomaly in cat-cry syndrome. The presence of interruption of the aortic arch (IAA) and abnormal CA origin has been previously reported to increase mortality. To decrease the risk of bronchomalacia in infants, bilateral pulmonary artery banding (PAB) was performed as the first stage procedure for adjusting the pulmonary flow. Staged repair is a useful strategy for infants with complex TA.

Bilateral Branch Pulmonary Artery Banding as a Bridge to Decision/Preoperative Optimization of High-Risk Neonates With Hypoplastic Left Heart Syndrome

We present our experience with bilateral branch pulmonary artery banding as a bridge to decision/optimization of hemodynamics, followed by standard Norwood stage I palliation in very high-risk infants with hypoplastic left heart syndrome.

Staged repair for aortic arch reconstruction and intracardiac repair following bilateral pulmonary artery banding in 3 critical patients

Bilateral pulmonary artery banding has been performed as a first palliation for hypoplastic left heart syndrome with a poor preoperative condition. We report 3 patients with aortic arch reconstruction and intracardiac repair following bilateral pulmonary artery banding in moribund patients after birth. Our patients successfully received arch reconstruction, pulmonary debanding and patch closure of the ventricular septal defect at the age of 2 or 3 months after birth with a body weight of 3.5 and 4.5 kg, respectively. No postoperative neurological deficits were observed, and postoperative morbidity was significantly reduced. More than 75% of cerebral oxygenation may provide higher urinary output due to higher renal blood flow through collateral circulation. This technique reduces the risk of perioperative neurological damage.

Flow-adjustable bilateral pulmonary artery banding in the neonatal period for severe congenital heart diseases

We perform bilateral pulmonary artery banding (BPAB) combined with postoperative percutaneous pulmonary artery balloon dilatation (PABD) as stage I palliation for severe congenital heart diseases. The objective of this study was to evaluate the efficacy of our management strategy for the treatment of severe congenital heart diseases. From October 2007 to March 2010, 9 consecutive patients underwent BPAB. Subsequently, all patients had a second-stage operation; we performed biventricular repair for 3 cases and univentricular repair for 6 cases. Clinical data were obtained by retrospectively reviewing medical records. There was no early mortality (30days). After the neonatal period, we controlled the pulmonary blood flow to be slightly elevated by PABD. Therefore, the Qp/Qs level was around 1.0, which might contribute to achieving good pulmonary artery growth and avoid intraoperative pulmonary arterioplasty. Except for one patient, intraoperative pulmonary arterioplasty in the second-stage operation was not necessary. Regarding Norwood procedure, an 8mm RV-PA (right ventricle-pulmonary artery) conduit was available for respective patients. Although further studies are warranted, our strategy might prove to be a valid clinical option for the treatment of severe congenital heart diseases.

Flow adjustable bilateral pulmonary artery banding in the treatment of Hypoplastic Left Heart Syndrome

Flow adjustable bilateral pulmonary artery banding in the treatment of Hypoplastic Left Heart Syndrome

両側肺動脈絞扼術を用いたCoA/IAA 複雑心奇形に対する二期的根治術

両側肺動脈絞扼術を用いたCoA/IAA 複雑心奇形に対する二期的根治術

両側肺動脈絞扼術後に根治手術（大動脈弓再建＋Rastelli 手術）を施行した総動脈幹症・大動脈弓離断症の1例

症例は女児．在胎41週1日，体重3,032 gで仮死なく出生し，生直後より心雑音とチアノーゼを認め心エコー検査にて総動脈幹症・大動脈弓離断症と診断された．同日よりプロスタグランディン製剤の持続静注が開始され，当院NICU緊急搬送された．肺血流増多に伴う多呼吸・尿量減少がみられたため，11生日に両側肺動脈絞扼術を施行した．術後に心不全症状は改善し体重増加が得られ，生後2カ月時に根治手術を行った．胸骨再正中切開下に心・大血管周囲を剥離した後に，腕頭動脈および下行大動脈送血を併用した上下半身分離体外循環下に大動脈弓再建（拡大直接吻合）し，心停止下に右室切開を置きVSDを閉鎖した．大動脈遮断解除後にあらかじめ作製しておいた二弁付12 mmGoreTex人工血管を用いて右室流出路再建を行った．人工心肺離脱は特に問題なく，開胸状態で手術を終了し3病日に閉胸し4病日に人工呼吸器を離脱した．術後に右横隔膜の軽度拳上に伴う頻呼吸があったが徐々に改善し，49病日に退院した．

The Norwood Procedure: In favor of the RV-PA Conduit

Evolution of the Norwood procedure has culminated in there currently being three treatment strategies available for initial management: the 'classical' Norwood (utilizing a Blalock-Taussig shunt), the Norwood with right-ventricle to pulmonary artery (RV-PA) conduit, and the 'hybrid' Norwood procedure utilizing bilateral pulmonary artery banding and ductal stenting. Each variant has its potential advantages and disadvantages, and this paper looks to examine the evidence in favor of each strategy, with emphasis on the supportive data for the RV-PA conduit. The 'classical' procedure has the benefit of the greatest accumulated surgical experience and avoids any incision into the ventricle. However, the diastolic run-off of the Blalock-Taussig shunt can cause hemodynamic instability and unpredictable coronary steal phenomenon. The RV-PA conduit has the advantage of maintaining diastolic pressure with a more stable postoperative course, but at the cost of a ventriculotomy that may have detrimental long-term sequelae. The 'hybrid' procedure has the advantage of avoiding cardiopulmonary bypass, but does not always secure coronary blood flow and has a high inter-stage morbidity and reintervention rate. The evidence shows that each technique may have its place in future management, and that treatment algorithms could emerge that direct the choice of procedure for specific patient groups.

Bilateral pulmonary artery banding for resuscitation in high-risk, single-ventricle neonates and infants: A single-center experience

Bilateral pulmonary artery banding with or without ductal stenting has been performed as a resuscitative intervention for patients considered at too high risk for conventional single ventricle palliation. The purpose of the present study was to determine the outcomes using this strategy. We performed a retrospective review of 24 patients with single ventricle anatomy who were younger than 3 months who had undergone bilateral pulmonary artery banding and ductal stenting or maintenance of prostaglandin E(1) from January 2007 to October 2011 at our institution. The echocardiographic, angiographic, operative, and clinical data were reviewed. Follow-up data were available for 100% of the patients. All 24 patients (13 male patients) underwent bilateral pulmonary artery banding at a median age of 8days (range, 2-44 days). Their gestational age was 38 weeks (range, 27-41 weeks), and their weight was 3.01 kg (range, 1.5-4.4 kg). The cardiac diagnoses included hypoplastic left heart syndrome/variant hypoplastic left heart syndrome in 18, unbalanced atrioventricular canal in 4, and tricuspid atresia in 2. In the hypoplastic left heart syndrome group, 9 (50%) had an intact or a highly restrictive atrial septum requiring open (n=1) or transcatheter (n=8) atrial septostomy with or without atrial stent placement (n=4). Ductal stenting was performed in 14 patients, and 10 patients were continued with prostaglandin E(1). Fifteen patients (62.5%) survived to undergo a Norwood procedure (n=7), comprehensive stage 2 (n=1), or primary cardiac transplantation (n=7). Of the 9 who died, support was withdrawn in 5 because of a contraindication to transplantation, 1 because of sepsis and/or multiorgan system failure, and 1 for whom palliative care was desired. Two died awaiting transplantation. All 7 patients who underwent a conventional Norwood operation survived to discharge, and 6 of the 7(85.7%) underwent bidirectional Glenn shunt placement. Of the 7 patients who underwent transplantation, 6(85.7%) were alive at a median follow-up of 33.6 months. Bilateral pulmonary artery banding with or without ductal stenting is an effective method of resuscitation for high-risk neonates and infants with a single ventricle, allowing for reasonable survival to conventional first-stage palliation or primary transplantation.

Abstract 19571: Atrial Septal Interventions After Ductal Stenting and Bilateral Pulmonary Artery Banding

Introduction Bilateral pulmonary artery banding with arterial duct stenting (H1) leaves the state of the atrial septum unresolved. Atrial communications can become restrictive and their management is an important problem. We reviewed our experience of atrial septal interventions (ASI) in H1 patients until their second stage procedure (H2). Methods and Results A retrospective analysis of the first 66 H1 patients between 2004 and 2011. Thirty-nine (59%) of these patients had hypoplastic left heart syndrome. 34/66 (52%) patients required 42 ASI. These were performed before (n=4), during (n=5) or after H1 (n=25). An ASI was frequently required for neonates on a path to a Fontan (29/48, 60%) or being bridged to transplantation (4/10, 40%), but was rare for borderline LV (1/8, 13%). An ASI was required if there was a small ASD on the initial echocardiogram (p<0.01). A variety of percutaneous techniques were used: balloon septostomy/septoplasty (including cutting balloons), stenting and radio-frequency perforation of the atrial septum. Directly measured trans-septal mean gradient decreased from 12mmHg (range 2-25 mmHg) to 1mmHg (range 0-10mmHg). There were three ASI related deaths and 6 major complications. Three patients with LV sinusoids/fistulae experienced acute myocardial ischaemia following ASI. ASI was associated with an increased risk of death prior to H2. Conclusion Catheter techniques can produce minimally restrictive atrial communications, but can be associated with post-procedural instability. In patients with coronary sinusoids, myocardial ischaemia may occur if there is a large increase in pulmonary blood flow.

Bilateral pulmonary arterial banding for complex transposition of the great arteries

Bilateral pulmonary arterial banding for complex transposition of the great arteries

Editorial Comment: Critical aortic stenosis with severe left ventricular dysfunction

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Two-stage biventricular rehabilitation for critical aortic stenosis with severe left ventricular dysfunction

Critical aortic valve stenosis (CAS) in the newborn is treated by balloon or surgical aortic valve intervention with nearly equal success, but the subset of patients with severe left ventricular (LV) dilation and dysfunction present a significant mortality risk. We describe a two-stage surgical management approach for those infants who represent an unusually high failure risk for either aortic valvotomy or conventional stage 1 single ventricle (Norwood) palliation because of severe LV dysfunction at the time of presentation. A two-stage surgical palliation was undertaken consisting of surgical aortic valvotomy, bilateral pulmonary artery banding and atrial septectomy (stage 1), followed by patch closure of the atrial septal defect, ligation of the ductus arteriosus and removal of the pulmonary artery bands (stage 2) with prostaglandin infusion continued between stages to maintain right ventricular contribution to systemic perfusion via the ductus arteriosus. Four neonates with CAS and severely depressed LV systolic function were treated using this strategy. LV dilation resolved and systolic function improved in three patients after 2, 2 and 4 weeks, enabling stage 2. LV dysfunction did not improve in one patient who expired before conversion to biventricular circulation. Of the three who proceeded to stage 2, one infant continued to have poor biventricular diastolic function that precluded conversion, and this patient also died. The remaining two infants are now alive and well at 34 and 44 months of age. These two had the most severe LV dilation (internal dimension Z-scores of 6.9 and 7.7) and the worst systolic function (fractional shortening 4 and 10%) at presentation, and both were born prematurely (32 and 35 weeks). A two-stage surgical approach may improve the likelihood of survival in selected patients with CAS presenting with severely depressed LV systolic function. Relief of LV distention may have contributed to the improvement of LV function in these infants.

Mortality and neurodevelopmental outcome at 1 year of age comparing hybrid and Norwood procedures

Neonates with hypoplastic left heart syndrome (HLHS) are at risk of high mortality and neurodevelopmental morbidity. As an alternative to Norwood-type stage I palliation, the hybrid procedure has been developed. It consists of bilateral pulmonary artery banding, catheter-based stenting of the arterial duct and balloon atrioseptostomy and delays open-heart surgery. Thus, it may be associated with a better outcome. The aim of this study was to determine the mortality and neurodevelopmental outcome in patients with HLHS and other univentricular heart (UVH) defects treated with hybrid or Norwood procedures. Thirty-one children (18 males) with HLHS and other UVH defects undergoing Norwood or hybrid procedure between 2004 and 2008 were consecutively enrolled. Mortality and neurodevelopmental outcome at 1 year of age were determined. One-year mortality was 36% (31% in the hybrid vs. 39% in the Norwood group, P=0.71). Predictors of mortality were lower birth weight (P=0.02), older age at first procedure (P=0.02) and smaller size of ascending aorta (P=0.05). Overall, median psychomotor development index (PDI) and mental development index (MDI) of the Bayley Scales of Infant Development II were lower than the norm of 100 [PDI 57 (49-99), P<0.001; MDI 91 (65-109), P=0.002]. No effect of surgical treatment on neurodevelopmental outcome was found. Predictors of impaired motor outcome were length of hospital stay (LOHS) (P=0.01), lower body weight at second procedure (P=0.004) and female sex (P=0.01). Predictors of impaired cognitive outcome were longer mechanical ventilation time (P=0.03), intensive care unit stay (P=0.04) and LOHS (P<0.001), respectively. Mortality at 1 year of age is comparable between patients undergoing hybrid and Norwood procedures. Early neurodevelopmental outcome is significantly impaired in patients with both HLHS and other UVH defects. Multicentre randomized studies are needed to determine the long-term neurodevelopmental outcome of children treated with the hybrid procedure.

Congenital giant cardiac tumor with severe left-ventricular inflow and outflow obstruction and arrhythmia treated with pulmonary artery banding and long-term amiodarone infusion

We report a congenital giant cardiac tumor that occupied the majority of left ventricular cavity with severe left ventricular inflow and outflow obstruction. The hemodynamics were similar to univentricular physiology. He was treated with prostaglandins and bilateral pulmonary artery banding. He had frequent supraventricular tachycardia associated with ventricular pre-excitation that was controlled by long-term administration of intravenous amiodarone. The patient died due to sepsis after 3 months.

Hypoplastic Left Heart Syndrome, Restrictive Patent Foramen Ovale, and Pulmonary Valve Stenosis: An Unusual Combination

An infant presented with a rare combination of hypoplastic left heart syndrome, restricted patent foramen ovale, and moderately dysplastic pulmonary valve. In preparation for heart transplantation, bilateral pulmonary artery banding was performed to protect the pulmonary vasculature.

Second-Stage Palliation After Bilateral Pulmonary Artery Bands for HLHS and its Variants—Which is Better, Modified Norwood or Norwood Plus Bidirectional Glenn?

Background. The purpose of this study was to evaluate the surgical outcomes and pulmonary artery (PA) development associated with a new strategy wherein the modified Norwood (N) procedure is performed at 1-2 months after bilateral pulmonary artery banding (PAB). Methods. Between January 2008 and February 2010, 16 patients underwent Norwood-type operation after previous bilateral PAB. For analysis, patients were divided into two groups. Group I (n = 11) underwent modified Norwood procedure with either right modified Blalock Taussig (RMBT) shunt (n = 4) or right ventricle to pulmonary artery (RV-PA) conduit (n = 7). Group II (n = 5) underwent Norwood procedure plus bidirectional Glenn anastomosis. Diagnoses were hypoplastic left heart syndrome in 6 and its variants in 10. Results. There was no surgical death and no late death. Pulmonary artery interventions were performed at the time of the Norwood procedure in 27% in Group I and in 100% in Group II (p < 0.05). Additional PA interventions were performed during the period of follow-up in 4 cases in Group I (36.4%), and in 4 cases in Group II (80.0%). Additional Blalock Taussig shunts were performed in 7 patients, resulting in significant increase in PA index. In all, four patients have reached total cavopulmonary connection, and one has undergone biventricular repair. Eight patients in Group I and one patient in II Group reached bidirectional Glenn anastomosis. In Gp II, two patients showed LPA narrowing or obstruction with PA index of 80 ± 12 mm(2)/m(2). Conclusions. Regarding the second-stage palliation after bilateral PAB, modified Norwood procedure with either RMBT or RV-PA conduit has some advantages compared with Norwood plus BDG with respect to subsequent pulmonary artery development. Additional BT shunt may contribute to PA development, even in the patients with Norwood procedure with RV-PA conduit.

Bilateral pulmonary artery banding for initial palliation in high-risk hypoplastic left heart syndrome

Bilateral pulmonary artery banding for initial palliation in high-risk hypoplastic left heart syndrome

Use of Mathematical Modeling to Compare and Predict Hemodynamic Effects Between Hybrid and Surgical Norwood Palliations for Hypoplastic Left Heart Syndrome

Combining bilateral pulmonary artery banding with arterial duct stenting, the hybrid approach achieves stage 1 palliation for hypoplastic left heart syndrome with different flow characteristics than those after the surgical Norwood procedures. Accordingly, we used computational modeling to assess some of these differences, including influence on systemic and cerebral oxygen deliveries. A 3-dimensional computational model of hybrid palliation was developed by the finite volume method, along with models of the Norwood operation with a modified Blalock-Tausig or right ventricle-to-pulmonary artery shunt. Hybrid circulation was modeled with a 7-mm ductal stent and bilateral pulmonary artery banding to a 2-mm diameter. A 3.5-mm conduit was used in the Blalock-Tausig shunt model, whereas a 5-mm conduit was used in the right ventricle-to-pulmonary artery shunt model. Coupled to all the models was an identical hydraulic network that described the entire circulatory system based on pre-stage 2 hemodynamics. This clinically validated multiscale approach predicts flow dynamics, as well as global cardiac output, mixed venous oxygen saturation, and systemic and cerebral oxygen delivery. Compared with either of the Norwood models, the hybrid palliation had higher pulmonary-to-systemic flow ratio and lower cardiac output. Total systemic oxygen delivery was markedly reduced in the hybrid palliation (Blalock-Tausig shunt 591, right ventricle-to-pulmonary artery shunt 640, and hybrid 475 mL · min(-1) · m(-2)). Cerebral oxygen delivery was similarly lower in the hybrid palliation. These computational results suggest that the hybrid approach may provide inferior systemic and cerebral oxygen deliveries compared with either of the 2 surgical Norwood procedures before stage 2 palliation.

Prenatal complex congenital heart disease with Loeys–Dietz syndrome

We report an infantile case of Loeys-Dietz syndrome prenatally diagnosed with congenital complex heart disease - double outlet right ventricle and interruption of the aortic arch. The patient also showed prominent dilatation of the main pulmonary artery. Emergency bilateral pulmonary artery banding was performed on the 9th day. However, on the 21st day, the patient died of massive bleeding due to rupture of the right pulmonary artery. Subsequently, a mutation of the TGFBR1 gene was detected. As cardiovascular lesions of Loeys-Dietz syndrome appear early and progress rapidly, the prognosis is generally poor. Patients require periodic examination and early intervention with medical therapy such as Losartan administration and surgical therapy. Early genetic screening is thought to be useful for the prediction of complications as well as vascular disease.