2. Introduction
• Pulmonary artery banding (PAB) is a simple surgical technique
to reduce pulmonary overcirculation in some congenital heart
disease and to provide long-term protection against irreversible
pulmonary hypertension as well as to maintain an optimal
systemic output in cases of a large left-to-right shunt or
univentricular heart defects
• First described in 1952, by Muller and Danimann, as a
treatment for large ventricular septal defect (VSD) and
excessive pulmonary blood flow (PBF) through the ‘creation of
pulmonary stenosis’ in a 5-month old infant.
Mavroudis et al. Pediatric cardiac surgery, Fourh edition, 2013:
27-51
3. Introduction
• 1980s, survival of neonates and infants with complex cardiac
defects and congestive heart failure (CHF) caused by large
VSDs, tricuspid atresia and other complex lesions unsuitable for
primary repair has been significantly improved by the use of
PAB
• Use of PAB has declined during the last decade, in favour of
early and primary repair, it still has a place in the treatment of
congenital heart disease with pulmonary overflow.
Mavroudis et al. Pediatric cardiac surgery, Fourh edition, 2013:
27-51
4. Pathophysiology
• Congenital heart defects with left-to-right shunting and unrestricted
pulmonary blood flow (PBF) due to a drop in pulmonary vascular
resistance result in pulmonary overcirculation leads to pulmonary
edema and CHF in the neonate
• Principle of PAB is the reduction of the diameter of the main pulmonary
artery, decreasing blood flow to the pulmonary branches and reducing
pulmonary artery pressure. Concomitant improvement of systemic
pressure, cardiac output and ventricular function can be expected in
patients with a large left-to-right shunt.
• A reduction of PBF also decreases the total blood volume returning to the
left ventricular (or the systemic ventricle) and often improves ventricular
function
• At the same time, PAB exposes the patient to the risk of low systemic
oxygen saturation as a consequence of unbalanced mixing between the
systemic and pulmonary venous blood or abnormal ventricular hypertrophy
Mavroudis et al. Pediatric cardiac surgery, Fourh edition, 2013:
27-51
5. Indications
• Swiss cheese type of multiple ventricular septal defects
• Multiple ventricular septal defects with coarctation
• Single ventricle with increased pulmonary blood flow (i.e.tricuspid
atresia) in preparation for eventual Fontan procedure
• Postponing the choice between biventricular and univentricular
repair in atrioventricular or ventricular septal defects (VSD) with
ventricular imbalance.
• Defects with complex anatomy, often associated with a common
atrioventricular connection or a criss-cross heart, where a
biventricular repair of better quality may be possible later in life when
the cardiac structures are bigger.
• Left ventricular preparation for an arterial switch operation.
• Left ventricle training in a patient with congenitally corrected
transposition of the great arteries for a “double switch” or to
reduction TR in CCTGA with tricuspid incompetence without sizeable
VSD Hoseinikhah et al, Indications, results and mortality of PA banding procedure : a Brief
review and five year experiences, Int J Pediatric 2016: 4 (5): 1733-44
6. Surgical Technique
Approach
• Median Sternotomy
• Left thoracotomy
Type
• Fix
• Adjustable
Mavroudis et al. Pediatric cardiac surgery, Fourh edition, 2013:
27-51
8. Trusler’s rule
Trusler's rule for circumference of band
- Simple defect (large VSD) = 24 mm + wt (kg)
- Mixing defect (single ventricle, transposition)
= 20 mm + wt (kg)
• The target distal pulmonary artery pressure (PAP) is
conventionally 30-50% of systemic for biventricular heart, while
it should be as close to the Fontan pressure (mean of 15 mm
Hg), as possible, in a univentricular situation
Kirklin JK. Kirklin/Barratt-Boyes cardiac surgery 4th ed.
Philadelphia: Elsevier Saunders; 2013. p.754
10. Complication
• Pulmonary artery branch stenosis, the pulmonary band can
migrate and be the cause of right pulmonary artery occlusion or
bilateral pulmonary artery stenosis
• Erosion or pseudo-aneurysm formation of the pulmonary artery
trunk
• Proximal placement of the band can lead to obstruction of
coronary blood flow by direct impingement, usually of the
circumflex coronary artery and also can distort the pulmonary
valve and ultimately create dysplastic changes in the pulmonary
valve leaflets
Hoseinikhah et al, Indications, results and mortality of PA banding procedure : a Brief
review and five year experiences, Int J Pediatric 2016: 4 (5): 1733-44
11. Outcome and prognosis
• Pulmonary artery banding (PAB) should result in improved
hemodynamics and overall clinical improvement in the patient.
The signs and symptoms of congestive heart failure (CHF)
should resolve or become medically manageable
• The mortality rate of pulmonary artery banding is clearly
associated more with the complexity of cardiac defect and
overall condition of the patients than with the procedure itself
• Current mortality rates for pulmonary artery banding are
reported in some series to be as low as 3-5%
Hoseinikhah et al, Indications, results and mortality of PA banding procedure : a Brief
review and five year experiences, Int J Pediatric 2016: 4 (5): 1733-44
12. Take Down PA Banding
• Performed at the time of intracardiac correction, median
sternotomy
• Generally, intracardiac repair performed first. The pulmonary
artery reconstruction can be done while patient is being
warmed.
• Simple removal is adequate (periode of weeks)
• All portion of the band should be removed
• Band left in place for more than a few months, the are of
banding must be either patched anteriorly or excised.
Mavroudis et al. Pediatric cardiac surgery, Fourh edition, 2013:
27-51
Takedown of a pulmonary artery band.
A, Pulmonary artery transection, removal of the band site, and end-to-end
reconstruction with interrupted absorbable suture.
B, Takedown of a pulmonary artery band with anterior polytetrafluoroethylene (PTFE)
patch placement.
