Pulmonary Artery Banding and Band Removal at Subsequent Total Repair

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In the presence of a large left-to-right shunt, pulmonary artery banding may be indicated to protect the lungs and to avoid development of pulmonary vascular obstructive disease when total repair of intracardiac anomalies is not possible or should be delayed until an older age. Banding can be performed through a left or right thoracotomy or median sternotomy, regardless of the position of the great vessels. Ideally, it is carried out through a fourth interspace lateral thoracotomy on the side ipsilateral to the main pulmonary artery. A SILASTIC®-impregnated Teflon® band is passed around the mid main pulmonary artery. If the band is placed more proximally and over the commissures of the pulmonary valve, thickening of valve leaflets may occur after surgery, which may result in development of a dysplastic pulmonary valve. If the band is placed too distally on the main pulmonary artery, it may encroach on and kink one or both pulmonary artery branches.

During banding, distal pulmonary arterial pressure is monitored by placing a small plastic catheter through a purse string suture. A second plastic catheter is placed in the ascending aorta for blood sampling and measurement of systemic pressure, although the same can be accomplished with a peripheral arterial catheter inserted before thoracotomy. Ideally, banding should reduce distal main pulmonary artery mean pressure to 25 to 30mmHg or 30% to 50% of mean systemic pressure. In most cases before banding, pulmonary arterial pressure will be equal to systemic pressure. When pulmonary vascular resistance is low before banding, mean pulmonary arterial pressure may be low. In this case, the pulmonary artery is constricted until there is a rise in systemic pressure. The final postband pressures should be similar to those mentioned above for children who initially have pulmonary artery hypertension.

If systemic outflow tract obstruction is present, the band has to be placed loosely, and ideal pressure changes may not be accomplished; this avoids ventricular hypertension as the result of double outlet obstruction. To check for this after banding is complete, a needle is passed into the distal main pulmonary artery and then proximal to the band to measure intraventricular pressure.

Peripheral arterial oxygen saturation (Fi02 = 0.5) should not change with banding. A drop of 5% is acceptable in patients with normally related great vessels. In the presence of d-transposition a drop of 10% is acceptable, but peripheral arterial oxygen saturation should not be reduced below 65% to 70%.

Pericardiotomy

constricting band around mid main pulmonary artery

Figure 5-43. Through a left fourth intercostal space thoracotomy and a pericardiotomy at the base of the heart, a left-sided main pulmonary artery is exposed. The band around the main pulmonary artery has been progressively tightened with interrupted sutures until the desired pressure changes are seen. It is fixed to the adventitia of the proximal main pulmonary artery with interrupted sutures that are placed on one half to two thirds of the circumference of the main pulmonary artery. The monitoring catheters in the distal pulmonary artery and ascending aorta are in place.

catheter in ascending aorta catheter in distal main pulmonary artery

-*- ceph constricting band around mid main pulmonary artery

Figure 5-43. Through a left fourth intercostal space thoracotomy and a pericardiotomy at the base of the heart, a left-sided main pulmonary artery is exposed. The band around the main pulmonary artery has been progressively tightened with interrupted sutures until the desired pressure changes are seen. It is fixed to the adventitia of the proximal main pulmonary artery with interrupted sutures that are placed on one half to two thirds of the circumference of the main pulmonary artery. The monitoring catheters in the distal pulmonary artery and ascending aorta are in place.

5-5-1. Band Removal at the Time of Total Repair

Pulmonary Artery Banding

main pulmonary arte roto my band ends separated

Figure 5-44. On cardiopulmonary bypass, band stitches are removed and the ends of the band separated. A longitudinal incision is made in the anterior wall of the main pulmonary artery at the band site.

main pulmonary arte roto my band ends separated

Figure 5-44. On cardiopulmonary bypass, band stitches are removed and the ends of the band separated. A longitudinal incision is made in the anterior wall of the main pulmonary artery at the band site.

Pulmonary Banding

intimai fibrous ridge intimai fibrous ridge caud

Figure 5-45. After all sutures are removed, the band can be removed from its bed. A posterior fibrous ridge over the band tunnel remains, and this tissue must be excised to prevent residual obstruction.

Figure 5-45. After all sutures are removed, the band can be removed from its bed. A posterior fibrous ridge over the band tunnel remains, and this tissue must be excised to prevent residual obstruction.

Pulmonary Banding

fibrous ridge incised to open bed of previous band

Figure 5-46. The fibrous ridge is incised transversely on the inner surface of the pulmonary artery to expose the intact adventitia of the lateral and posterior main pulmonary artery.

fibrous ridge incised to open bed of previous band

Figure 5-46. The fibrous ridge is incised transversely on the inner surface of the pulmonary artery to expose the intact adventitia of the lateral and posterior main pulmonary artery.

Pulmonary Artery Banding Surgery

fibrous ridge

Figure 5-47. The fibrous ridge is excised also removing loose intimal tissue.

fibrous ridge caud

Figure 5-47. The fibrous ridge is excised also removing loose intimal tissue.

Pulmonary Banding

bed of previous band

Figure 5-48. The smooth adventitia of the posterior main pulmonary artery is intact. If it were not, the intima would be approximated with a continuous suture.

bed of previous band

Figure 5-48. The smooth adventitia of the posterior main pulmonary artery is intact. If it were not, the intima would be approximated with a continuous suture.

Patch Dacron
pericardia patch
Pulmonary Artery Banding

caud

Figure 5-49. An oval pericardial patch of generous size is sutured over the anterior main pulmonary artery.

caud

Figure 5-49. An oval pericardial patch of generous size is sutured over the anterior main pulmonary artery.

Pulmonary Stenosis
Figure 5-50. With placement of the pericardial patch, the main pulmonary artery is enlarged anteriorly to avoid stenosis of the vessel. The posterior fibrous rim has been removed to avoid obstruction to flow in this area, which can occur if only anterior pericardial patch enlargement is used.

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Your heart pumps blood throughout your body using a network of tubing called arteries and capillaries which return the blood back to your heart via your veins. Blood pressure is the force of the blood pushing against the walls of your arteries as your heart beats.Learn more...

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Responses

  • topias
    How dangerous is pulmonary artery banding?
    8 years ago
  • amanda
    How is a pulmonary artery band removed?
    4 years ago

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