Catheter balloon adjustment of the pulmonary artery band: feasibility and safety

Transcatheter balloon angioplasty of internal pulmonary artery bands to improve pulmonary blood flow: a case series

Pulmonary artery banding (PAB) is used to restrict pulmonary blood flow in select patients with large left-to-right intracardiac shunts or unrestrictive pulmonary blood flow prior to eventual surgical repair or palliation. More recently, surgical placement of an internal or intraluminal PAB (IPAB) has been used to restrict pulmonary circulation. Here we present two patients who underwent balloon angioplasty of the IPAB to treat cyanosis and improve pulmonary blood flow.

Contemporary Applications and Outcomes of Pulmonary Artery Banding: An Analysis of The Society of Thoracic Surgeons Congenital Heart Surgery Database

BACKGROUND

Pulmonary artery banding (PAB) in isolation or combined with a congenital cardiac surgical procedure is common and has important mortality. We aimed to determine patient characteristics, clinical outcomes, variation in clinical outcomes by diagnoses, and center variation in PAB use.

METHODS

Using The Society of Thoracic Surgeons Congenital Heart Surgery Database (STS CHSD), this study evaluated outcomes of patients undergoing PAB across diagnoses, participating centers, and additional procedures. Patients were identified by procedure and diagnosis codes from 2016 to 2019. We separated patients into groups of main and bilateral PAB and described their outcomes, focusing on patients with main PAB.

RESULTS

This study identified 3367 PAB procedures from 2016 to 2019 (3% of all STS CHSD cardiovascular cases during this period): 2677 main PAB, 690 bilateral PAB. Operative mortality was 8% after main PAB and 26% after bilateral PAB. There was significant variation in use of main PAB by center, with 115 centers performing at least 1 main PAB procedure (range, 1-134; Q1-Q3, 8-33). For patients with main PAB, there were substantial differences in mortality, depending on timing of main PAB relative to other procedures. The highest operative mortality (25%; P < .0001) was in patients who underwent main PAB after another separate procedure during their admission, with extracorporeal membrane oxygenation being the most frequent preceding procedure.

CONCLUSIONS

PAB is a frequently used congenital cardiac procedure with high mortality and variation in use across centers. Outcomes vary widely by banding type and patient diagnosis. Main PAB after cardiac surgical procedures, especially extracorporeal membrane oxygenation, is associated with very high operative mortality.

Congenital heart disease: addressing the need for novel lower-risk percutaneous interventional strategies

INTRODUCTION

With the advent of improved neonatal care, increasingly vulnerable higher-risk patients with complex congenital heart anomalies are presenting for intervention. This group of patients will always have a higher risk of an adverse event during a procedure but by recognising this risk and with the introduction risk scoring systems and thus the development of novel lower risk procedures, the rate of adverse events can be reduced.

AREA COVERED

This article reviews risk scoring systems for congenital catheterization and demonstrates how they can be used to reduce the rate of adverse events. Then novel low risk strategies are discussed for low weight infants e.g. patent ductus arteriosus (PDA) stent insertion; premature infants e.g. PDA device closure; and transcatheter pulmonary valve replacement. Finally, how risk is assessed and managed within the inherent bias of an institution is discussed.

EXPERT OPINION

There has been a remarkable improvement in the rate of adverse events in congenital cardiac interventions but now, as the benchmark of mortality rate is switched to morbidity and quality of life, continued innovation into lower risk strategies and understanding inherent bias when assessing risk will be key to continuing this improvement.

Pulmonary artery debanding in the cath lab: Lessons learned!

Background

Although primary definitive repair of congenital heart disease has become the preferred management approach, pulmonary artery banding (PAB) remains a valuable palliative procedure used to restrict pulmonary blood flow in certain conditions. However, when the band is to be removed, another surgical intervention is usually required.

Methods

To describe percutaneous removal of pulmonary artery band, the medical records of patients who underwent this procedure were reviewed.

Results

Between 2000 and 2020, 143 patients underwent PAB. Of these, we attempted balloon debanding of the pulmonary artery in four patients. At the time of the procedure, the average age of patients was 36 ± 6.24 months, and their average weight was 12.37 kg. Band removal via catheter was successful in three cases and was associated with an adequate reduction in pressure gradient across the pulmonary artery band site (average of 71.67 ± 12.58 to 23.67 ± 2.89 mm Hg). None of the patients experienced complications during or after the procedure. Follow-up data after discharge (3-10 years) provides reassuring and satisfactory results.

Conclusion

Based on our findings, we suggest that percutaneous removal of the pulmonary artery band might be a safe and effective alternative to surgical debanding. However, studies with a larger sample are required for further clinical implementation of the technique.

Dilatable pulmonary artery banding for ventricular septal defect: surgical technique and case report of three cats

Pulmonary artery banding (PAB) is a viable but underreported palliative option for hemodynamically significant ventricular septal defect in small animals. A significant challenge associated with PAB is judging the degree of band tightening, which can be further complicated when animals are immature and still growing at the time of PAB. If a pulmonary artery band is overtightened or becomes progressively too tight after surgery, the result can be reversal of shunt flow with potentially devastating consequences. Placement of a band that could be percutaneously dilated using a balloon catheter affords a minimally invasive option for partially or completely relieving the band should it become too tight after PAB. This report describes a surgical technique for placement of a dilatable pulmonary artery band, reviews guidelines for tightening the band, and reports the outcome of three cats undergoing the procedure. All three cats showed evidence of reduced hemodynamic load after PAB for a period of up to three years after PAB.

Surgical palliation of univentricular heart disease in children with Down's syndrome: A systematic review

Objectives

No standard protocol is available for the management of children with Down's syndrome (DS) and a functional single ventricle. This review attempts to determine the outcomes of the single ventricular surgical palliation pathway in high-risk children with DS.

Methods

Several databases were searched using the following MeSH terms: ‘Congenital heart disease’, ‘Atrioventricular septal defect’, ‘Balanced AVSD’, ‘Unbalanced AVSD’, ‘Down's syndrome’, ‘Univentricular repair’, ‘bidirectional Glenn procedure’, and ‘Fontan procedure’. A structured algorithm was used for the selection of studies for an in-depth analysis.

Results

There was no universal agreement on the best surgical approach for unbalanced atrioventricular septal defect in DS. The majority of paediatric cardiac surgeons did not recommend the complete Fontan procedure; conversely, the use of a Glenn shunt (superior cavopulmonary connection) was preferred.

Conclusions

Careful assessment of the suitability for Fontan surgery, including the absence of elevated pulmonary vascular resistance, pulmonary arterial anatomy, and function of the dominant ventricle, is mandatory. A staged surgical procedure ending with complete Fontan repair provides acceptable medium-term results.

Pulmonary artery debanding

Pulmonary artery banding is a simple palliative surgical procedure for congenital heart defects with left-to-right shunt or complete mixing and pulmonary over-circulation. Even though indication for pulmonary artery banding has been sensibly reduced, since early reparative surgery has been proved superior to palliation and a staged approach, an increasing support for pulmonary banding has been raised in the last two decades by new indications such as left ventricular retraining, in the late arterial switch operation for complete transposition of the great arteries or before the double-switch operation in congenitally corrected transposition. Along with the increasing interest raised by the new indications and the consequently more diffuse use of banding, debanding has become an important surgical issue. Debanding is usually performed several months after palliation along with the repair of the cardiac malformations; otherwise, it can be done progressively or partially to further delay surgery and let the patient grow. Occasionally, after pulmonary artery banding, a spontaneous resolution of the underlying cardiac malformation can occur; however, a debanding procedure is in any case necessary.