Pulmonary artery banding (PAB) is a technique of palliative surgical therapy used by congenital heart surgeons as a staged approach to operative correction of congenital heart defects. This technique was widely used in the past as an initial surgical intervention for children born with cardiac defects characterized by left-to-right shunting and pulmonary overcirculation. Within the last decade, early definitive intracardiac repair has largely replaced palliation with pulmonary artery banding. This trend has evolved because many centers have demonstrated improved outcomes with primary corrective surgery as an initial intervention in the neonate with congenital heart disease. Although the use of pulmonary artery banding has recently significantly decreased, it continues to maintain a therapeutic role in certain subsets of patients with congenital heart disease.
The primary objective of performing pulmonary artery banding is to reduce excessive pulmonary blood flow and protect the pulmonary vasculature from hypertrophy and irreversible pulmonary hypertension. More recently, pulmonary artery banding has played a role in the preparation and “training” of the left ventricle (LV) in patients with D-transposition of the great arteries (d-TGA) who are evaluated for a delayed arterial switch procedure. It has found a similar role in training the LV in patients with L-transposition of the great arteries (L-TGA) who may also be candidates for an arterial switch procedure.
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 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 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.
History of the Procedure
The first description of pulmonary artery banding 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 pulmonary artery banding has declined, it remains an essential technique for comprehensive surgical treatment in patients with congenital heart disease.
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