Palliative Pulmonary Artery Banding Research Articles

Bidirectional glenn surgery without palliative pulmonary artery banding in univentricular heart with unrestricted pulmonary flow. Retrospective multicenter experience

BackgroundAlthough pulmonary artery banding (PAB) has been generally acknowledged as an initial palliative treatment for patients having single ventricle (SV) physiology and unrestrictive pulmonary blood flow (UPBF), it may result in unfavorable outcomes. Performing bidirectional Glenn (BDG) surgery without initial PAB in some selected cases may avoid the complications associated with PAB and reduce the number of operative procedures for these patients. This research aimed to assess the outcome of BDG surgery performed directly without doing initial PAB in patients with SV-UPBF.MethodsThis Multicenter retrospective cohort includes all patients with SV-UPBF who had BDG surgery. Patients were separated into two groups. Patients in Group 1 included patients who survived till they received BDG (20 Patients) after initial PAB (28 patients), whereas patients in Group 2 got direct BDG surgery without first performing PAB (16 patients). Cardiac catheterization was done for all patients before BDG surgery. Patients with indexed pulmonary vascular resistance (PVRi) ≥ 5 WU.m2 at baseline or > 3 WU.m2 after vasoreactivity testing were excluded.ResultsCompared with patients who had direct BDG surgery, PAB patients had a higher cumulative mortality rate (32% vs. 0%, P = 0.016), with eight deaths after PAB and one mortality after BDG. There were no statistically significant differences between the patient groups who underwent BDG surgery regarding pulmonary vascular resistance, pulmonary artery pressure, postoperative usage of sildenafil or nitric oxide, intensive care unit stay, or hospital stay after BDG surgery. However, the cumulative durations in the intensive care unit (ICU) and hospital were more prolonged in patients with BDG after PAB (P = 0.003, P = 0.001respectively).ConclusionDirect BDG surgery without the first PAB is related to improved survival and shorter hospital stays in some selected SV-UPBF patients.

Anatomic considerations in the management of complete atrioventricular canal.

Patients with complete atrioventricular canal have a variable clinical course prior to repair. Many patients balance their circulations well prior to elective repair. Others manifest clinically significant pulmonary over circulation early in life and require either palliative pulmonary artery banding or complete repair. The objective of this study was to assess anatomic features that impact the clinical course of patients. In total, 222 patients underwent complete atrioventricular canal repair between 2012 and 2022 at a single institution. Twenty-seven (12%) patients underwent either pulmonary artery banding (n = 15) or complete repair (n = 12) at less than 3 months of age (Group 1). The remaining 195 (88%) underwent repair after 3 months of age (Group 2). Patient records and imaging were reviewed. The median post-operative length of stay following complete repair was 25 [7,46] days for those patients in Group 1 and 7 [5,12] days for those in Group 2 (p < 0.0001). There was relative hypoplasia of left-sided structures in Group 1 versus Group 2. Mean z-score for the ascending aorta was -1.2 (±0.8) versus -0.3 (±0.9) (p < 0.0001), the aortic isthmus was -2.1 (±0.8) versus -1.4 (±0.8) (p = 0.005). The pulmonary valve to aortic valve diameter ratio was median 1.47 [1.38,1.71] versus 1.38 [1.17,1.53] (p 0.008). Echocardiographic evaluation of the systemic and pulmonary outflow of patients with complete atrioventricular canal may assist in predicting the clinical course and need for early repair vs pulmonary artery banding.

Expectant management of prolonged hemolysis following complete transcatheter coil closure of a patent ductus arteriosus after previous pulmonary artery banding: a case report

BackgroundTranscatheter coil occlusion has been the treatment of choice for closure of small patent ductus arteriosus (PDA). In spite of its safety, complications such as hemolysis still occasionally occur. And the hemolysis almost always occurs following partial transcatheter closure of PDA; hence, it occurs extremely rarely following complete transcatheter closure of PDA without residual ductal flow.Case presentationHere, we describe a male newborn who developed prolonged hemolysis following complete transcatheter coil closure of his PDA after previous palliative pulmonary artery banding. Over the following days, we corrected his refractory anemia by repeated blood transfusion with packed red blood cells and frequently monitored his hemoglobin, serum total bilirubin, and serum lactate dehydrogenase. We speculated that the high-velocity pulmonary blood flow jet coming into contact with the extruded part of the coil led to red blood cell mechanical injury, thereby resulting in the hemolysis. We adopted expectant management in expectation of the endothelialization of the coil with a resultant reduction in the hemolysis. The hemolysis, as expected, was reduced gradually until it spontaneously resolved 81 days after coil implantation.ConclusionsThis case reminds us that hemolysis can still potentially occur following complete transcatheter coil closure of PDA. It also highlights the importance of preventing coils from extruding into the pulmonary artery in patients after previous pulmonary artery banding.

Recent advances in managing septal defects: ventricular septal defects and atrioventricular septal defects.

This review discusses the management of ventricular septal defects (VSDs) and atrioventricular septal defects (AVSDs). There are several types of VSDs: perimembranous, supracristal, atrioventricular septal, and muscular. The indications for closure are moderate to large VSDs with enlarged left atrium and left ventricle or elevated pulmonary artery pressure (or both) and a pulmonary-to-systemic flow ratio greater than 2:1. Surgical closure is recommended for large perimembranous VSDs, supracristal VSDs, and VSDs with aortic valve prolapse. Large muscular VSDs may be closed by percutaneous techniques. A large number of devices have been used in the past for VSD occlusion, but currently Amplatzer Muscular VSD Occluder is the only device approved by the US Food and Drug Administration for clinical use. A hybrid approach may be used for large muscular VSDs in small babies. Timely intervention to prevent pulmonary vascular obstructive disease (PVOD) is germane in the management of these babies. There are several types of AVSDs: partial, transitional, intermediate, and complete. Complete AVSDs are also classified as balanced and unbalanced. All intermediate and complete balanced AVSDs require surgical correction, and early repair is needed to prevent the onset of PVOD. Surgical correction with closure of atrial septal defect and VSD, along with repair and reconstruction of atrioventricular valves, is recommended. Palliative pulmonary artery banding may be considered in babies weighing less than 5 kg and those with significant co-morbidities. The management of unbalanced AVSDs is more complex, and staged single-ventricle palliation is the common management strategy. However, recent data suggest that achieving two-ventricle repair may be a better option in patients with suitable anatomy, particularly in patients in whom outcomes of single-ventricle palliation are less than optimal. The majority of treatment modes in the management of VSDs and AVSDs are safe and effective and prevent the development of PVOD and cardiac dysfunction.

Insights gained from three-dimensional imaging modalities for closure of ventricular septal defects.

Ventricular septal defects (VSDs) are the commonest group of congenital heart lesions, accounting for ≈30% of congenital heart defects in liveborn infants.1 Defects in the ventricular septum are classified according to their position when the ventricular septum is viewed from the right ventricle and these may vary in their location, size, and number.2,3 VSDs can occur as isolated lesions or as part of more complex disease, for example, transposition of the great arteries or double outlet right ventricle, where the location and size of such defects assume great importance in planning the optimal mode of surgical repair.4 In most cases, surgical closure remains the mainstay treatment for VSDs, but selected lesions may be amenable to catheter closure.5,6 Cross-sectional echocardiography is the most commonly used noninvasive diagnostic method to delineate the position of a VSD before surgery.7 Multiple sonographic cuts and cross-sectional sweeps of the region of interest are used to build a virtual reconstruction of the three-dimensional (3D) anatomy in the mind of the echocardiographer. However, for the surgeon who deals solely with 3D images there can remain an element of uncertainty when called to operate on the patient. The number, size, location of VSDs, and their relationship to adjacent structures are central for selecting whether the defects might be best closed via the tricuspid valve, via the semilunar valves, or via a ventriculotomy or whether these might not be readily approachable and a palliative pulmonary artery banding is desirable.8,9 In this review, we present key 3D echocardiographic projections and examples of different types of VSDs where the images have a direct effect on the approach taken to VSD closure. Comparison of 3D echocardiography (3DE) with other 3D imaging modalities is also described. Images are presented in an …

Palliative pulmonary artery banding versus anatomic correction for congenitally corrected transposition of the great arteries with regressed morphologic left ventricle: Long-term results from a single center

We aimed to compare the long-term results between palliative pulmonary artery banding and anatomic correction for congenitally corrected transposition of the great arteries with regressed morphologic left ventricle. From 2003 to 2012, 40 consecutive patients underwent first-stage pulmonary artery banding. The second-stage operation-double switch-was performed in 15 patients (double-switch group). The other 25 patients retained pulmonary artery banding without further operation (pulmonary artery banding group). In-hospital mortality, long-term mortality, and heart function were studied as primary outcomes. The median time of follow-up was 3.4±0.7 years (range, 6 months-9.5 years). Overall survival rate was 66.7% in the double-switch group versus 96.0% in the pulmonary artery banding group (P=.03). The ratio of New York Heart Association functional class I-II (80.0% vs 95.9%; P=.02) and the mean functional left ventricle ejection fraction (51.4%±9.6% vs 61.0%±6.4%; P=.01) were higher in the pulmonary artery banding group at follow-up. In univariate analysis, age at pulmonary artery banding was the only risk factor for late deaths (odds ratio, 7.30; P=.01) and left ventricle dysfunction (odds ratio, 4.77; P=.03) after the double switch. For patients who experienced prolonged pulmonary artery banding, mean oxygen saturation was 95%±3.1% and the trans-banding pressure gradient was 46.9±21.5 mm Hg. In patients with congenitally corrected transposition of the great arteries with deconditioned morphologic left ventricle pulmonary artery banding may be considered an ideal procedure because it allows left ventricle training while improving tricuspid regurgitation. Compared with the double-switch procedure after pulmonary artery banding, prolonged palliative pulmonary artery banding provided a lower mortality rate and indicated better cardiac function.

The palliative pulmonary banding may provide better outcomes than anatomical correction of congenitally corrected transposition of the great arteries with involuted morphologic left ventricle

Background: Recently sub-optimal outcomes were reported after the second stage anatomical correction of congenitally corrected transposition of the great arteries (cc-TGA) with morphologic Left Ventricular (mLV) regression. We followed up all the patients underwent Pulmonary Artery Banding (PAB) with/without the second stage Double Switch (DS) operation to compare the outcomes between the DS and the prolonged palliative PAB. Methods: From 2005 to 2012, 40 consecutive patients diagnosed with cc-TGA with morphological LV regression were included in this retrospective cohort study. Every patient underwent the first stage PAB. The second stage DS was performed in 15 patients (group I) while the palliative PAB was prolonged in the other 25 patients (group II). The median age at PAB was 3.1 years (range, 3 months to 8 years) and the mean weight at PAB was 11.5kg (range, 5.0-21.5kg). Mean follow-up was 3.4±0.7years (range, 6 months to 9.5 years). Results: Overall survival rate was 66.7% in group I vs. 96.0% in group II (P=0.03). Three patients had at least moderate neo-aortic regurgitation at latest echocardiography and 2 patients had severe post-double switch operative arrhythmias in group I. The ratio of NYHA I–II (80.0% in group I vs. 95.9% in group II, P=0.02) and the mean systemic ventricular ejection fraction (51.4±9.6% in group I vs. 61.0±6.4% in group II, P=0.006) were higher in group II at follow up. No PAB relating cyanosis or ventricular dysfunction was found in group II. The trans-banding pressure gradient was 46.9±21.5mmHg in group II. View this table: Outcomes between groups Conclusions: The results of the mLV retraining followed by a DS procedure for cc-TGA with morphological LV regression were unsatisfactory. Compared to the DSO, the prolonged pallative PAB provided a lower mortality and indicated a better cardiac function. As a result, performing the DSO on these patients needs careful consideration and the prolonged pallative PAB may be considered as an ideal procedure. Further follow-up is warranted with a focus on the exercise tolerance.

Left Ventricular Function After Left Ventriculotomy for Surgical Treatment of Multiple Muscular Ventricular Septal Defects

Optimal management of muscular ventricular septal defects (MVSD) is still not determined in the current era. Moreover, long-term left ventricular function after closure of MVSD is not well known. Thus, we investigated surgical outcomes including long-term left ventricular function after closure of MVSD through left ventriculotomy. We conducted a retrospective review of medical records of 20 children who underwent MVSD closure between March 1993 and August 2010. There were 10 boys (50%) and 10 girls (50%). Patient age ranged from 1.6 to 103.4 months (median, 26.4 months), and body weight from 2.8 to 31.5 kg (median, 11.9 kg). Electrocardiogram results were normal sinus rhythm in all except 1 patient with congenital complete atrioventricular block. There were 16 patients who previously had palliative pulmonary artery banding procedures before closure of MVSD. There were 13 patients (65%) with Swiss-cheese type VSD. There was 1 hospital death of a patient with congenital complete atrioventricular block with pacemaker malfunction (5%). There was 1 late death of a patient with del 22q with adenoviral pneumonia. There was no reoperation. Median follow-up duration was 85.9 months (range, 4.7 to 166.7). The location of MVSD was apical portion in 10 patients (50%) and midtrabecular portion in 9 patients (45%). There were 6 Dacron patch closures and 13 direct closures of MVSD through left ventriculotomy. There was no complete atrioventricular block. Last follow-up echocardiographic data showed normal ejection fraction with 65.2% ± 8.2% after closure of MVSDs. There was no leakage in 8 patients; 11 patients had insignificant leakage, which disappeared spontaneously in 4 patients 17.9 months (median value) after operation. Our acceptable long-term results of left ventricular function after left ventriculotomy proved that this technique might be a viable option in the management of MVSD.

Thrombolytic therapy for prosthetic valve thrombosis in children: two case reports and review of the literature

Thrombotic occlusion of a mechanical valve prosthesis can be life threatening and requires urgent evaluation and treatment. Traditionally, the treatment for mechanical valve thrombosis has been urgent reoperation with attempted declotting of the valve or valve rereplacement. Unfortunately, this is associated with a high mortality, and efforts have been made to pursue nonoperative treatment with thrombolytics. There are many reports of the successful use of thrombolytics in adults, but very little data are reported in the pediatric population. We review the literature, report 2 cases of successful treatment of mechanical mitral valve thrombotic occlusion with thrombolytic therapy in children, and summarize the major reports of thrombolytic use for prosthetic valve occlusion in the pediatric population.

Trends in the Management of Truncal Valve Insufficiency

Background. The single semilunar valve in patients with truncus arteriosus frequently is dysplastic and dysfunctional. Truncal valve insufficiency has been associated with poor outcome. Although the management of truncal valve insufficiency has evolved over the years, approaches to this problem vary considerably and remain a serious dilemma in many cases. Methods. We reviewed the records of 89 patients with unrepaired truncus arteriosus and mild (n = 37), moderate (n = 33), or severe (n = 19) truncal valve insufficiency who were admitted to our institution between 1975 and 1995. Eight patients (7 neonates) with moderate or severe insufficiency died before surgical intervention, and 4 patients underwent palliative pulmonary artery banding. The remaining 77 patients underwent repair. The median age at repair was 3.2 months (range, 2 days to 15 years; 83% infants), and it decreased from 4 months between 1975 and 1985 to 1 month between 1986 and 1995. Truncal valve replacement (mechanical = 6, allograft = 4) was performed in 10 patients, and 5 patients underwent valve repair. Results. All 4 patients who underwent pulmonary artery banding died either early or late. The hospital (or 30-day) mortality rate after repair was 34% (26/77). At a median follow-up of 10 years, 11 hospital survivors had died, with overall 1- and 10-year actuarial survival rates of 56% and 48%, respectively, and poorer survival among patients with severe truncal valve insufficiency ( p = 0.02). Late truncal valve replacement (n = 24) had been performed in 21 patients. Freedom from truncal valve replacement was better in patients with mild truncal insufficiency than in those with moderate or severe preoperative insufficiency ( p < 0.001). Four late deaths were related directly to reoperation for truncal valve replacement or to prosthetic valve dysfunction. Three of the 4 neonates who received allograft root replacements died within 7 months of repair, and severe allograft valve insufficiency requiring replacement 1 year after operation developed in the fourth. Conclusions. The prospects for patients with truncal valve insufficiency have been improving over time. Nevertheless, the results in patients with severe insufficiency continue to be poor.

Complete atrioventricular septal defects: the influence of associated cardiac anomalies on surgical management and outcome

Major associated cardiac anomalies are known to increase the risk of repair of complete atrioventricular septal defects (CAVSDs). The purpose of this study was to examine the effects of such anomalies on the current surgical management of CAVSDs and their influence on outcome following repair. We performed a retrospective review of a 100 consecutive non-isomeric patients undergoing repair of CAVSD at our institution, between January 1989 and December 1994; patients with partial or intermediate defects were excluded. Complete atrioventricular septal defect patients with other major cardiac abnormalities (complex) were then compared to those with isolated CAVSDs. There were 15 patients (15%) with associated anomalies; 3 had tetralogy of Fallot, 1 patient had pulmonary atresia, 6 had hypoplastic left or right ventricle, 1 had tetralogy of Fallot and hyperplastic right ventricle, 2 patients had double outlet right ventricle, 1 had hypoplastic aortic arch and 1 patient had aortic coarctation. The median age at operation was similar for both groups (4.2 months), while the median weight was not significantly different for isolated CAVSDs compared to complex (4.2 months vs 3.4 months, P = 0.89), but there was a higher incidence of trisomy 21 (70/85, 82% vs 8/15, 53.3%, P = 0.01). Two of the 85 isolated CAVSD patients (2.3%) had undergone palliative pulmonary artery banding, while 5 of the 15 complex patients (33.3%) had either banding or Blalock-Taussig shunts performed. The technique of CAVSD repair was identical in each group. All complex patients had standard repair of their associated anomalies. Hospital mortality was higher in the complex group (3/15, 20% vs 2/85, 2.3%, P = 0.004); all early deaths in the complex group occurred in patients with a hypoplastic ventricle. Reoperation for left atrioventricular valve regurgitation was required in six isolated CAVSD patients (7.1%) and in one complex (6.6%). In the absence of significant ventricular hypoplasia, the early results of surgical repair in patients with CAVSDs and associated cardiovascular anomalies are similar to those achieved in patients with isolated CAVSD.

Primary surgical closure of large ventricular septal defects in small infants

Herein, a policy of primary surgical closure of large ventricular septal defects in infants is reviewed. Fortyeight infants met criteria for inclusion in the study, and were divided into two groups based on weight: group 1 infants weighed 4 kg or less (n = 23), and group 2 infants weighed more than 4 kg (n = 25). Both groups had similar variation in ventricular septal defect location (paramembranous versus muscular) and number (single versus multiple), as well as incidence of major associated extracardiac diseases. No early deaths occurred in group 1, compared with 1 infant (4%) in group 2. Major complications occurred similarly in both groups (9% versus 12%). There were two late deaths in group 1 (9%) and none in group 2. No surviving patients have required a second ventricular septal defect operation, and the majority no longer receive anticongestive therapies. These results indicate that primary surgical closure of large ventricular septal defects, even multiple muscular defects, can be performed in very small infants with no difference in mortality or serious complication rates compared with larger infants. Protracted medical efforts to achieve larger size before primary repair and palliative pulmonary artery banding are not necessary.

Surgical treatment of interrupted aortic arch in infancy with expanded polytetrafluoroethylene grafts: Two-year follow-up results

The interrupted aortic arch complex is an uncommon but highly lethal combination of anomalies. Multiple approaches have been proposed for the surgical treatment of this complex. These include palliative procedures, direct anastomosis of the interrupted segments, interposition grafting with biological or synthetic conduits, and total correction by closure of the atrial and ventricular septal defects with anastomosis of the proximal and distal aortic segments. This communication reports the good clinical results, noted after 2 years of follow-up, in two consecutive patients with type B interrupted aortic arch who underwent operative repair of the interrupted arch with expanded polytetrafluoroethylene (PTFE) grafts and palliative pulmonary artery banding.

Total Correction of Ventricular Septal Defect in Infancy Using Extracorporeal Circulation: Surgical Considerations and Results of Operation

Between 1955 and 1970, 143 Mayo Clinic patients less than 2 years old (78 boys and 65 girls; ages 10 weeks to 24 months, median age 14 months) underwent total correction of a ventricular septal defect using extracorporeal circulation. The distribution of associated lesions was as follows: 66% had no other lesions, 11% had an atrial septal defect, 9% had pulmonary stenosis, 8% had a patent ductus arteriosus, and 6% had other lesions. Two patients were asymptomatic; clinical features in the remainder included congestive heart failure (76%), failure to thrive (55%), and repeated respiratory infections (32%). Operative mortality was inversely related to age and weight. Neither of the asymptomatic patients died. The overall mortality was 21% for the entire interval; for the most recent five-year period, the rate was 10% (22% for infants less than 12 months and 0% for those 12 to 24 months). These data compare favorably with our previous experience and that of others for palliative pulmonary artery banding in infancy followed by correction at a later age, and they support our current approach of closure of the ventricular septal defect using extracorporeal circulation in almost all infants who require surgical aid.