Pulmonary artery banding (PAB) is a palliative surgical technique for congenital heart defects, primarily used to reduce excessive pulmonary blood flow and protect the pulmonary vasculature. Although its usage has declined due to more definitive surgical interventions, PAB remains important for specific patients, especially those with transposition of the great arteries or significant left-to-right shunting. The procedure involves placing a band around the pulmonary artery to manage blood flow and prevent heart failure, with careful consideration of patient selection, anatomical factors, and postoperative care.

1. Pulmonary artery banding
Raja Lahiri

2. • Pulmonary artery banding (PAB) is a technique of
palliative surgical therapy used by congenital heart
surgeons as a staged approach for operative correction of
congenital heart defects.
• This technique was widely used in the past as an initial
surgical intervention for infants born with cardiac defects
characterized by left-to-right shunting and pulmonary
overcirculation.
• Within the last two decades, early definitive intracardiac
repair has largely replaced palliation with PAB.
• Although the use of PAB has recently significantly
decreased, it continues to maintain a therapeutic role in
certain subsets of patients with congenital heart disease.

3. • The primary objective of performing PAB is to
reduce excessive pulmonary blood flow and
protect the pulmonary vasculature from
hypertrophy and irreversible (fixed) pulmonary
hypertension.
• More recently, PAB has played a role in the
preparation and "training" of the left ventricle
(LV) in patients with D- TGA who are evaluated
for a delayed arterial switch procedure.

4. History of the Procedure
• The first description of pulmonary artery banding (PAB) in the
literature was a report by Muller and Dammann at the University of
California, Los Angeles (UCLA) in 1951.
• In this report, Muller and Dammann described palliation by the
"creation of pulmonary stenosis" in a 5-month-old infant who had a
large ventricular septal defect (VSD) and pulmonary overcirculation.
• Following this report, multiple studies were published demonstrating
the effectiveness of this technique in infants with congestive heart
failure (CHF) caused by large VSDs, complex lesions (eg,
atrioventricular canal [AVC] defects), and tricuspid atresia.
• Although the use of PAB has declined, it remains an essential
technique for comprehensive surgical treatment in patients with
congenital heart disease. PAB is a palliative but not a curative
surgical procedure.

5. 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.
• In the acute setting, this leads to pulmonary edema and congestive heart
failure (CHF) in the neonate.
• Within the first year of life, this unrestricted flow and pressure can lead to
medial hypertrophy of the pulmonary arterioles and fixed pulmonary
hypertension.
• Pulmonary artery banding (PAB) creates a narrowing, or stenosing, of the
main pulmonary artery (MPA) that decreases blood flow to the branch
pulmonary arteries and reduces PBF and pulmonary artery pressure.
• In patients with cardiac defects that produce left-to-right shunting, this
restriction of PBF reduces the shunt volume and consequently improves
both systemic pressure and cardiac output.
• A reduction of PBF also decreases the total blood volume returning to the
LV (or the systemic ventricle) and often improves ventricular function.

6. Indications
• Patients who are selected for pulmonary artery banding
(PAB) and staged cardiac repair are determined based on the
experience and training of the pediatric cardiologists and
congenital heart surgeons at any given institution.
• Most of these patients fall into 2 broad categories:
(1) those with pulmonary overcirculation and left-to-right
shunting who require reduction of pulmonary blood flow
(PBF) as a staged approach to more definitive repair and
(2) those with transposition of the great arteries (TGA) who
require training of the left ventricle (LV) as a staged approach
to the arterial switch procedure.

7. Patients in the first category who are considered for PAB
include those with the following diagnoses:
• Multiple muscular ventricular septal defects (VSDs) with a
"Swiss cheese" septum that is technically difficult to
repair in the neonate or requires a ventriculotomy
• Single or multiple VSDs with coarctation of the aorta or
interrupted aortic arch, or contraindications to primary
repair, including very low birth weight, major extracardiac
conditions, major chromosomal abnormalities,
pneumonia, recovering from shock, sepsis, multisystem
organ failure, and intracranial hemorrhage

8. • Single ventricle defects
• Unbalanced atrioventricular canal (AVC) defects in
which the LV is hypoplastic but the potential exists for
a 2-ventricle repair with further growth and
development
• Cardiac defects that require a homograft conduit (eg,
D-TGA with subpulmonic stenosis ) for complete
repair: Use of PAB may allow time for growth of the
patient before the complete repair. Interim growth of
the patient permits placement of a larger conduit at
the time of repair and potentially increases the
longevity of the conduit and length of freedom from
reoperation.

9. Patients in the second category who are considered for
PAB include those with the following diagnoses:
• D-TGA that requires preparation of LV for an arterial
switch procedure following initial late presentation or
diagnosis in patients older than 1 month or older than
about 6-8 weeks of age with signs of LV
deconditioning.
• D-TGA that requires preparation of LV for an arterial
switch procedure following a previous Mustard or
Senning procedure with the development of right
ventricular failure or L-TGA that requires preparation
of the LV prior to the double switch procedure.

10. • Patients with single ventricle physiology and
unrestricted PBF are suitable for an early PAB to
prevent development of congestive heart failure
(CHF) and pulmonary hypertension. This group of
patients may include those who have tricuspid atresia
with unrestrictive VSD, unbalanced AVC defect, and
double inlet LV.
• Patients who have single ventricle physiology and
pulmonary overcirculation should undergo PAB in the
first 1-2 months of life to avoid irreversible
pulmonary hypertension that may complicate or
preclude a subsequent Fontan procedure

11. • Currently, most patients with D-TGA undergo an
arterial switch procedure within the first few weeks of
life. However, some newborns with D-TGA and an
intact ventricular septum may not undergo an early
arterial switch procedure because of active infections,
coexistent noncardiac diseases, or a delay in diagnosis.
• Because of the risks of neonatal repair, neonates with
D-TGA and multiple VSDs may benefit from bilateral
PAB prior to definitive repair later in infancy. This
technique may be less prone to damaging the
neoaortic valve and root dilation than banding of the
main pulmonary artery.

12. • PAB is also used in patients with D-TGA who
develop right ventricular dysfunction after a
Mustard or Senning atrial switch procedure.
• The PAB is required for a longer period than
preparation of the ventricle in infants (<12
months).
• Although the overall early survival rate
approaches 90%, approximately one half of
these patients require heart transplantation
because of the progression of coexisting left
ventricular failure.

13. • Recent application of PAB has been reported in
patients with diagnosis of L-transposition or
physiologically corrected transposition of the great
arteries.
• This group of patients may present with failing
systemic RV.
• Using the same principle, the PAB is used to retrain
the LV in preparation for a double switch operation,
a combination of an atrial and arterial switch.
• This operation places the LV as the systemic ventricle
and the mitral valve as the systemic AV valve. This
achieves anatomic repair of the malformation.

14. • Another application of PAB is in patients with
elevated, but reactive, pulmonary
hypertension from long-standing left-to-right
shunting.
• An immediate surgical repair may carry
significant morbidity and even mortality. With
the use of a PAB and pulmonary vasodilator,
some of these patients may drop their
pulmonary vascular resistance and
subsequently respond more favorably to
surgery.

15. Anatomical considerations
• In most patients with cardiac defects requiring pulmonary artery
banding (PAB), the length of main pulmonary artery (MPA) is
sufficient to allow placement of the band in the mid portion of the
artery without impingement on either the pulmonary valve,
coronary arteries proximally or the branch pulmonary arteries
distally.
• The inferior wall of the right pulmonary artery (PA) arises slightly
more proximal on the MPA than the left PA. The right PA also arises
from the MPA at more of an acute angle. Both of these factors
increase risk of right PA impingement by a distally placed band.
• In patients with pulmonary overcirculation, the MPA may be quite
large compared to the aorta. Additionally, the MPA vessel wall may
be thinned out by this dilatation, and the adventitia may be quite
attenuated. These changes increase risk of tearing the wall of the
MPA at the time of PAB.

16. Contraindications
• Patients who have single ventricle defects in which the
aorta arises from an outflow chamber (eg, double inlet left
ventricle [LV], tricuspid atresia with transposition of the
great arteries [TGA]) have the potential for development of
significant subaortic obstruction.
• Pulmonary artery banding (PAB) is contraindicated in the
presence of such obstruction and in patients who are at
high risk for such obstruction.
• The ventricular hypertrophy that develops in response to
PAB may cause rapid progression of subaortic obstruction
leading to a combination of both ventricles having outflow
tract obstruction and progressive hypertrophy.

17. • Bilateral PAB may be useful prior to complete repair in the
setting of low birth weight, prematurity, major associated
extracardiac conditions, severe preoperative acidosis not
correctable by medical therapy, pneumonia, as a staged repair
in truncus arteriosus with interrupted aortic arch, and/or a
combination of these factors.
• Bilateral PAB can be achieved using a 3.0-mm or 3.5-mm
Goretex graft placed around the right and left pulmonary
arteries
• Bilateral PAB has also been used as a bridge to decision
regarding biventricular versus univentricular palliation. For
example, bilateral PAB with maintenance of ductal patency may
allow time for adequate growth of a left ventricle so that the
infant can undergo biventricular repair. The pulmonary artery
bands can also be dilated in case of desaturation, to allow
further time before definitive surgery.

18. Workup
• Routine laboratory tests are obtained preoperatively in the
assessment of a patient being considered for pulmonary artery
banding (PAB).
• Baseline arterial oxygen saturations should be obtained by
either pulse oximetry or ABG analysis.
• A baseline creatinine level should be obtained and compared
postoperatively during diuresis and management of congestive
heart failure (CHF).
• The hemoglobin and hematocrit should be optimized to
improve oxygen carrying capacity and oxygen saturations
following PAB.
• Imaging and/or diagnostic procedures include
echocardiography, magnetic resonance imaging with 3-
dimensional reconstruction, and/or cardiac catherization.

19. • Preoperative treatment of patients with pulmonary
overcirculation and congestive heart failure (CHF) should
focus on minimizing left-to-right shunting, improving cardiac
function with inotropic support, systemic afterload
reduction, and aggressive diuresis.
• Mechanical ventilator support may be necessary to maintain
adequate ventilation and oxygenation in the setting of
pulmonary edema.
• Maintaining higher carbon dioxide levels and lower fraction
of inspired oxygen (FIO2) during ventilation may assist in
reducing pulmonary blood flow (PBF) and pulmonary
edema.
• If a patent ductus arteriosus (PDA) is present, attempts
should be made to reduce or close it with medical therapy
(eg, indomethacin) to reduce this source of PBF.

20. Surgical approach
• Three standard surgical approaches to pulmonary artery
banding (PAB) have been established, depending on the
need to perform additional procedures at the time of
band placement.
– As an isolated procedure, PAB can be performed through an
anterior left thoracotomy in the second or third interspace
– If performed in conjunction with a coarctation or interrupted
aortic arch repair, a left lateral thoracotomy is used and the
chest is entered through the third or fourth intercostal space
– In patients with single ventricle physiology, TGA or in whom
an adjunct procedure is required, a median sternotomy
incision is preferred

22. • Patients may benefit from placement of a band that can
be easily and quickly tightened or loosened, both at the
initial procedure and during subsequent interventions.
The ability to readjust the band is particularly useful in
patients who exhibit dynamic changes in cardiac output,
pulmonary vascular resistance, and systemic vascular
resistance.
• Adjustable bands are also helpful in patients with AV
valve regurgitation, particularly complex AV canal
defects. The acute increase in afterload that
accompanies PAB may exacerbate AV valve insufficiency.
Staged tightening of the band is usually well tolerated
and allows improvement in insufficiency by decreasing
ventricular volume overload.

23. • The MPA and aorta are exposed, and the band is
prepared for placement.
• The estimated band circumference is marked on the
umbilical tape with fine sutures according to the Trusler
formula.
• PAB circumference in patients with noncyanotic
nonmixing lesions (eg, ventricular septal defect [VSD]) is
20 mm + 1 mm/kg body weight. For patients with mixing
lesions (eg, D-transposition of the great arteries [TGA]
with VSD), the formula is 24 mm + 1 mm/kg body weight.
In patients with single ventricles in whom the Fontan
procedure is planned, an intermediate circumference of
22 mm + 1 mm/kg body weight is preferred.

24. • The site of band placement is carefully selected in the mid
portion of the MPA trunk, and distortion or injury to the
pulmonary valve or impingement on the branch pulmonary
arteries is avoided.
• Dissection is performed in the adventitia between the aorta
and the MPA, and it is limited to prevent proximal or distal
band migration.
• The MPA is handled very carefully because it often is dilated,
thin-walled, and susceptible to injury. Regardless of the
operative approach, injuries to the posterior wall of the MPA
can be difficult to repair because of limited exposure.
• Generally, the band is first passed through the transverse
sinus to encircle both the aorta and MPA. The aortic end of
the band is then carefully delivered between the aorta and
the MPA through the previous site of dissection

26. • The marked sites on the band are identified and
aligned with each other on the anterior wall of the
MPA.
• The band is snared with a short segment of #8 or
#10 polyethylene tubing and fixed with medium
hemoclips.
• A felt or pericardial pledget is placed beneath the
band between the end of the snare and the MPA
wall to prevent injury to the artery from the snare.
• The pledget and band material are then anchored
to the MPA adventitia to prevent band migration

29. • Physiologic assessment to determine the appropriate
tightness of the PAB includes intraoperative
measurements of the proximal and distal PA
pressures, systemic blood pressure, and arterial
oxygen saturation by pulse oximetry (or by direct
measurement of arterial blood gas sampling).
• The goal of PAB is to produce a distal PA pressure that
is 30-50% of systemic pressure.
• Lower saturations of 75-80% may be acceptable in
patients with single ventricle physiology. The target
pressure for univentricular hearts is 15mmHg (Fontan
pressure)

30. • Failure to achieve these levels in patients with
mixed circulations suggests inadequacy of the
interatrial communication.
• In such patients, addition of an atrial
septectomy or septostomy may be indicated.
• In addition to changes in PA pressure and
systemic oxygen saturation, one ideally should
note a concomitant rise in systemic arterial
pressure of 10-15 mm Hg.

31. • An adequate atrial communication should be confirmed
preoperatively in patients with single ventricle physiology,
including transposition with VSD complexes. A balloon
atrial septostomy is useful in these situations.
• Kotani and colleagues measured intraoperative aortic
blood flow using a Transonic flow probe and found that
aortic blood flow increased by approximately 40% after
successful PAB. Their data suggested that higher pre-PAB
Qp/Qs (pulmonary [Qs]-systemic [Qp] blood flow ratio)
predicted a higher percentage increase in aortic flow.
• Three patients with less than a 20% increase in aortic
blood flow died, required re-PAB, or developed
ventricular dysfunction.

32. • Aortic blood flow in these patients did not increase even
when the band was tightened further than indicated
with the Trusler formula.
• Kotani et al concluded that the limited response to PAB
in terms of increases in aortic blood flow is a
nonmutable marker of decreased cardiac reserve, as
opposed to a parameter that can be targeted by further
adjustment of pulmonary artery band circumference (ie,
making it tighter).
• The current practice is a combination of anatomic
(Trusler formula) and physiologic (indexed aortic blood
flow pre-PAB and post-PAB, in addition to change in
systemic blood pressure and SaO2) assessment during
surgery.

33. • PAB takedown is usually performed at the time of the
intracardiac repair through a median sternotomy.
Generally, the repair is completed first and the PAB
removal is performed at the end of the procedure.
• The band is dissected free from surrounding scar tissue
and removed. The area of banding usually remains
stenotic and requires repair.
• This repair can be achieved by resection and end-to-end
anastomosis of the proximal and distal MPA or by
vertical incision of the MPA followed by pericardial (or
polytetrafluoroethylene [PTFE]) patch repair of the
arteriotomy
• The repair must ensure relief of any branch PA stenosis
that may exist as a consequence of the PAB.

35. Post-op care
• Patients undergoing PAB are initially treated in the intensive care
unit (ICU).
• They often benefit from a course of intravenous inotropic support
and require careful attention to fluid balance and volume status.
• Following PAB, improved hemodynamics and greater left
ventricular output often allow for diuresis and gradual resolution
of CHF.
• The assessment of a patient following PAB should ideally be made
under conditions of balanced volume status and in the absence of
atelectasis or ongoing pulmonary pathology.
• Although measured parameters from the operating room are
helpful guidelines, the overall clinical status of the patient is the
most important assessment.

36. • This includes changes in systemic blood pressure,
heart rate, oxygen saturation, and overall cardiac
function. Hypotension, bradycardia, and ischemic
electrocardiographic changes all indicate an
excessive band gradient and imminent cardiac
failure or arrest.
• The advantage of an adjustable PAB is that it allows
for rapid loosening of the band with a hemoclip
remover in the ICU, if necessary. Catheter
debanding is also an invaluable technique in
selected cases.

37. • Evaluation of the PAB is made by color flow Doppler
echocardiography at the bedside; it usually provides an
accurate assessment of band tightness, band gradient,
band position, and overall cardiac function.
• Any impingement or stenosis of the branch pulmonary
arteries can also be observed with this study. Rarely,
cardiac catheterization and direct measurement of PA
pressure and band gradient is necessary.
• More recently, cinemagnetic resonance imaging d 3-
dimensional reconstruction have been useful as
noninvasive methods of evaluation.

38. Follow-up
• Most patients undergoing pulmonary artery banding
(PAB) for pulmonary overcirculation are monitored for 3-
6 months and then undergo more definitive repair of
their cardiac defect.
• The degree of right ventricular hypertrophy that
develops in response to any given PAB gradient varies
greatly among infants. Those infants who develop rapid
and severe right ventricular hypertrophy in response to
PAB should be considered for earlier definitive repair to
prevent long-term right ventricular dysfunction.

39. • Patients with D-TGA who undergo PAB for
training of the LV must be monitored with
serial echocardiography to assess "readiness"
of the LV before the arterial switch operation.
• After either technique, patients are monitored
with serial echocardiography that allows
quantitative measurements of left ventricular
mass index, as well as qualitative assessment
of ventricular septal geometry.

40. • Left-to-right septal bowing is an indication that
the LV can generate near-systemic pressure. Left
ventricular preparation is usually accomplished
within 7-10 days, after which patients may
undergo an arterial switch procedure, takedown
of shunt, and PAB.
• The early mortality rate is 4-5%, only slightly
greater than that for a primary arterial switch
procedure. In infants, this may be several weeks,
but older children may require longer periods of
banding to achieve adequate results.

41. Complications
• Although pulmonary artery banding (PAB) is a seemingly
simple operation, it has been associated with numerous
complications. One of the most common complications of PAB
is impingement and stenosis of one or both of the branch
pulmonary arteries. The right pulmonary artery (PA) is involved
in most cases of branch stenosis for anatomic reasons already
mentioned.
• The diagnosis of branch PA impingement is often suggested by
a chest radiograph that shows asymmetric vascular markings
between the right and left lungs.
• Definitive diagnosis can usually be made by echocardiography,
and fractional pulmonary blood flow (PBF) to each lung can be
determined with radionuclide lung perfusion scanning.

42. • If significant branch stenosis is uncorrected, it can
lead to underdevelopment of the involved lung
with alveolar hypoplasia. Early recognition of
branch PA stenosis should allow a revision of the
PAB before the development of this late sequela.
• Limiting dissection of the tissue between the aorta
and the main pulmonary artery (MPA) and fixing
the band with sutures on the proximal MPA
adventitia both reduce risk of this complication.
Use of the incisional PAB technique prevents distal
band migration and generally avoids this
complication.

43. • Conversely, if the band is placed too proximal on
the MPA, it may distort the pulmonary valve and
ultimately create dysplastic changes in the
pulmonary valve leaflets.
• This is particularly devastating when PAB is
performed as preparation for an arterial switch
procedure because the pulmonary valve becomes
the neo-aortic valve after the arterial switch
procedure. In addition, proximal placement of the
band can lead to obstruction of coronary blood
flow by direct impingement, usually of the
circumflex coronary artery

44. • Anomalous origin of a coronary artery may
increase risk of this complication.
• These complications can generally be avoided
by placement of the band more than 15 mm
distal to the pulmonary valve cusps.
• Preoperative demonstration of coronary
anatomy is helpful, but intraoperative
vigilance during the banding procedure should
avoid these types of complications.

45. • In patients with erosion of the band into the
PA, scarring and fibrosis around the band site
usually prevents the life-threatening bleeding
from occurring. Hemolytic anemia and local
thrombus formation have been reported.
• Erosion seems to occur with increased
frequency when narrow banding material is
used, although it can occur with any material.
Pulmonary artery pseudoaneurysm is a rare
complication of PAB.

46. • PA pseudoaneurysm may be preceded by local
infection and, like band erosion, is heralded by
loss of the band murmur and gradient.
Imaging studies demonstrate an enlarged
mediastinal shadow on chest radiography and
a markedly enlarged PA on echocardiography
or MRI.
• The diagnosis of PA pseudoaneurysm
formation mandates urgent surgical
intervention.

47. • Repair is performed on cardiopulmonary bypass
with patch repair of the MPA. Glutaraldehyde-
treated autologous pericardium is preferred to
synthetic material because this condition is
sometimes associated with infection.
• An additional complication is an ineffectual PAB
either from a loose band at the original
procedure or later disruption of the band or
erosion of the PA.

48. • The results of an ineffectual band are excessive
PBF and early recurrence or continuation of
congestive heart failure (CHF). In addition,
pulmonary vascular disease with irreversible
pulmonary hypertension may potentially
develop.
• Loss of band murmur and recurrence of CHF after
PAB suggests loosening or erosion of the band.
• Early evaluation and close follow-up should
allow revision before the onset of irreversible
changes.

49. 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,
cardiomegaly should decrease, and pulmonary vascular
resistance should decrease.
• PAB affords protection to the pulmonary vasculature
against fixed irreversible pulmonary hypertension
secondary to pulmonary overcirculation and elevated
pulmonary artery (PA) pressures.

50. • The mortality rate of PAB is clearly associated
more with the complexity of cardiac defect
and overall condition of the patients than with
the procedure itself.
• Patients who are selected for PAB and a staged
repair are often chosen because they are
considered too high risk to undergo definitive
repair. Therefore, the mortality rates from
earlier series have been as high as 25%.

51. • A decreasing mortality rate with PAB can be
related to improved operative techniques,
better patient selection, and timing of
intervention.
• Additionally, improvements in anesthetic and
postoperative management have also resulted
in a decreased mortality rate. Mortality rates
for PAB are reported in some series to be as
low as 3-5%.

52. Future and Controversies
• Almost half a century since the introduction of pulmonary artery
banding (PAB) by Muller and Dammann, this procedure still has a
defined role in the treatment of infants who are not candidates for
immediate definitive repair.
• In particular, it may be useful in patients with a functional single
ventricle not amenable to early repair and in whom a future Fontan
procedure is planned.
• It may also benefit patients with excessive pulmonary blood flow who
are considered too ill to undergo complete repair of their cardiac
defect.
• Interestingly, the original technique of an incisional band as described
by Muller and Dammann has resurfaced as a desirable technique in
some patients.

53. • The adjustable band technique has proved useful
and safe for most patients. Interest has been
shown for the development of an intraluminal
technique for PAB using circular patches of
fenestrated material.
• This requires a cardiopulmonary bypass to
perform and is therefore limited in its applicability
to most patients. Ongoing research to develop a
percutaneously adjustable, thoracoscopically
implantable, pulmonary artery band is underway.

54. • Additionally, research is being conducted in
animals to develop a hydraulic main pulmonary
artery (MPA) constrictor as an adjustable PAB.
• These types of devices would benefit patients
who require multiple adjustments of a PAB for
left ventricle (LV) training.
• An implantable device for PAB with telemetric
control, FloWatch-R-PAB (Endoart SA,
Lausanne, Switzerland) has emerged from
animal studies and is currently in clinical trials.

55. • Early clinical results have shown the efficacy
and reliability of the device, but more data
and experience are needed to define the role
of this technology in PAB.
• A percutaneously adjustable PAB technique
has been developed for LV training. Other
groups have developed percutaneously
adjustable devices.

56. • A strategy of deferring biventricular repair by the
application of a pulmonary artery band may not
be applicable in developing and third world
conditions primarily due to lack of patient
compliance.
• A study by Brooks et al indicates that less than
50% are eventually repaired in a reasonable time
frame. Moreover, patient follow-up is unreliable.
• Thus, in such circumstances, consideration
should be given to early definitive repair, even in
perceived high-risk cases.

57. • More recently, PAB has been proposed as a
treatment modality for LV dilated
cardiomyopathy with preserved RV function as
an additional strategy to delay or even avoid
heart transplantation in infants and young
children with terminal heart failure.
• The rationale is similar to that for training of
the morphologic LV in corrected transposition
of the great arteries (TGA).

58. Conclusion
• For most patients undergoing PAB, the goal of the
procedure remains reduction of pulmonary blood flow
(PBF) and preservation of pulmonary vessels from
hypertrophy and hypertension.
• More recently, a new indication of preparing the LV for
arterial switch in older infants and children with D-TGA
appears to have expanded the role of this procedure.
• Although some surgeons would contend that PAB is largely
of historical interest, this technique clearly will continue to
maintain a place in the therapeutic armamentarium of the
congenital heart surgeon.

59. THANK YOU