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Objective To investigate the effects of banding width on hemodynamic characteristics of pulmonary artery (PA) by constructing pulmonary artery banding (PAB) models with different widths. Methods Based on clinical practice, with the same banding position and degree, computer-aided design (CAD) was utilized to reconstruct three-dimensional PAB models with different banding widths (2, 3, 4, 5 mm). Hemodynamic characteristics of the models with different banding widths, including pressure, streamlines, energy loss, energy efficiency and blood flow distribution ratio, were compared and analyzed through computational fluid dynamics (CFD). Results The pressure of PA decreased significantly, while the change of banding width had no significant effects on the pressure drop level at banding position. With the increase of banding width, the energy loss decreased, and the energy efficiency showed an upward trend. The blood flow of the left PA raised, and the ratio of blood flow distribution between the left PA and right PA increased, with the maximum reaching up to 2.28 : 1. Conclusions The increase of banding width can reduce the energy loss of PA and improve the energy efficiency of blood flow, but it will lead to the imbalance of blood flow distributions between the left and right lungs. Both the balance of blood flow distribution and the energy loss should be considered in choice for banding width of PAB. The virtual design of PAB surgery based on CAD and CFD will assist individualized banding width selection in future.
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Systemic-pulmonary shunt for neonate and small infant with decreased pulmonary blood flow is an important first palliative surgery as simple palliation or complex palliative open-heart surgery to affect the completeness of subsequent radical or second surgery. It is important to understand the hemodynamics according to each disease and determine the shunt design considering the “shape” and “flow rate” of the shunt. In recent years, Blalock-Taussig shunt (BT shunt) and central shunt through median sternotomy have become mainstream, however conventional BT shunt through lateral thoracotomy is still an important basic procedure which pediatric cardiac surgeons should learn. Pulmonary artery banding (PAB) or bilateral PAB is also an important palliative procedure to protect the right and left pulmonary vascular beds equally for pulmonary high-flow complex heart disease and functional single ventricle. It is essential to perform secure PAB or bilateral PAB, which leads to the next procedure smoothly.
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Objective@#To examine the early- and midterm outcomes of pulmonary artery banding as an initial palliation in patients with single ventricle associated with unrestricted pulmonary blood flow.@*Methods@#Between January 2008 and December 2017, 49 patients with single ventricle and unrestricted pulmonary blood flow underwent pulmonary artery banding at Department of Cardiac Surgery, Guangzhou Women and Children′s Medical Center, Guangzhou Medical University. There were 29 males and 20 females. The age at the time of surgery was 5.6 (11.5) months (M(QR)), and the weight was 5.2 (3.9) kg. The medical records and results after pulmonary artery banding (death/reoperation, transition to the Glenn procedure) and subsequently after the Glenn procedure (death, transition to the Fontan procedure) were reviewed retrospectively. Actuarial survivals were estimated by the Kaplan-Meier curve. Relative factors for affecting outcomes were analyzed using the Cox regression hazard model.@*Results@#There were 8 early deaths, with a mortality of 16.3%, including 4 cases who received simultaneous arch repair. There were 5 late deaths. During the follow-up of 47(62) (M(QR)) months, 11 patients (22.4%) underwent pulmonary artery banding adjustment, 29 patients (59.2%) underwent the Glenn procedure, 21 patients (42.8%) underwent the Fontan procedure. The survival of patients after the initial pulmonary artery banding were 77.4% (95%CI: 65.6% to 89.2%) and 72.6% (95%CI: 59.9% to 85.3%) at 1 year and 5 years, respectively. Multivariate Cox regression analysis revealed that systemic ventricular outflow tract obstruction (HR=4.25, 95%CI: 1.50 to 12.03, P=0.006) and total anomalous pulmonary venous connection (HR=6.49, 95%CI: 3.24 to 12.98, P=0.000) were relative factors for death.@*Conclusions@#The early and midterm outcomes of pulmonary artery banding as an initial palliative strategy is not satisfactory. Systemic ventricular outflow tract obstruction and total anomalous pulmonary venous connection are associated with high mortality.
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Total anomalous pulmonary venous connection (TAPVC) is rarely associated with remarkably small left heart structures. In these types of cases, the hemodynamics resembles that of hypoplastic left heart syndrome, and the treatment strategy is controversial. We present the case of a 1-day-old girl with infracardiac TAPVC, small left heart structures (hypoplastic left heart complex), bilateral superior <i>vena cava</i>, and aberrant origin of the right subclavian artery. We performed a semi-emergent first-stage open palliation for repair of TAPVC, because of pulmonary venous obstruction. We concomitantly performed atrial septal defect (ASD) enlargement and bilateral pulmonary artery banding (BPAB). The postoperative course was uneventful and the left heart structures did not grow, so we performed the Norwood procedure and placed a right ventricle-pulmonary artery shunt with a 5.0 mm artificial graft. Subsequently, the left heart structures were not suitable for biventricular repair, so we chose univentricular repair. The patient underwent a bilateral bidirectional Glenn operation and Fontan completion at 6 and 23 months of age, respectively. TAPVC repair, BPAB, and ASD enlargement are reasonable surgical options for a patient with borderline small left heart structures and TAPVC, as they enable us to wait for growth in the left heart structures and to determine whether univentricular or biventricular repair is suitable.
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We performed bilateral pulmonary artery banding (BPAB) through a median sternotomy on a four-day-old male infant with a double-outlet right ventricle (DORV) and interrupted aortic arch (IAA) who was delivered at 40 weeks of gestation. After urinary output improved, definitive repair was carried out 5 days later. Intra-ventricular rerouting was followed by arterial switch with the Lecompte maneuver. The aortic arch was reconstructed with direct anastomosis and the right ventricular outflow tract was augmented with a patch. The sternum was left open at the end of the procedure and the chest was closed on post-operative day (POD) 4. The patient was discharged from hospital on POD 78 after receiving treatment for pneumonia and chylothorax.
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A baby girl delivered at 41 weeks of gestation with persistent truncus arteriosus (PTA) and interrupted aortic arch (IAA) type A was referred to our institute for surgical intervention. Bilateral pulmonary artery banding (BPAB) proceeded through a median sternotomy at the age of 11 days to control excessive pulmonary blood flow. Thereafter, she gained weight under continuous prostaglandin E1 (PGE 1) infusion. Definitive repair proceeded at the age of 2 months. Cardiopulmonary bypass was established through a redo-median sternotomy, with two arterial cannulae (brachiocephalic artery and descending aorta). The aortic arch was reconstructed with direct anastomosis. The orifice of the pulmonary artery was removed from the arterial trunk and the defect in the aortic wall was directly closed. A ventricular septal defect was closed under cardioplegic arrest via a right ventriculotomy. The continuity from the right ventricle to the pulmonary artery was made using a hand-made, extended polytetrafluoroethylene (ePTFE) conduit with a bicusp. The sternum was left open at the end of the procedure and the chest was closed on post-operative day (POD) 3. She was weaned from mechanical ventilation on POD 4 and the postoperative course was uneventful. She was discharged on POD 49.
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ObjectiveContrast research the operative effect of the pulmonary artery banding (PAB) in the congenital heart disease with pulmonary artery hypertension,underwent the single ventricle repair procedure in different age.Methods 49 cases,male 31 and female 18.Age (7.8 ± 3.8 ) years old,weight ( 8.82 ± 4.24) kg,percutaneous blood oxygen saturation ( SPO2 ) 0.90 ± 0.04,preoperative mean pulmonary artery pressure (mPAP) ( 54.6 ± 16.8 ) mm Hg.single ventricle 13cases,tricuspid atresia 12 cases,double outlet of right ventricle with left ventricular dysplasia 11 cases,tricuspid stenosis 5 cases,ventricular imbalance type complete atrioventricular canal defect 5 cases and cross heart cases 3 cases.divided into three groups:≤0.5 years old of 17 cases,0.5 to 2.0 years old of 17 cases,≥2.0 years old 15 cases.All cases taken PAB under anesthesia and cpb,inhaled oxygen concentration 40％,SPO2 0.85,MPAP 20 mmHg.comparatively analysis postoperative SPO2,MPAP,Ventilator using time,ICU stay time and operation mortality of the three groups.ResultsThe postoperative PAP obviously decreased.Three groups of postoperative SPO2,mPAP,ventilator using time,ICU stay time were not significantly different.More than were followed up 6-72 months,1 cases ( 1-2 months) dead in aspiration two months postoperation.the other three cases had been completed Glenn and/or Fontan.ConclusionPAB can effectively reduce the pulmonary artery pressure in the different age children with congenital heart disease and pulmonary artery hypertension,the effect is good.more than 2 years old children still PAB feasible operation,and likely to complete the Glenn and/or Fontan procedure.
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ObjectiveTo identify the suitable echocardiographic predictor of speckle tracking imaging (STI) for evaluation of development of left ventricle(LV) after pulmonary artery banding (PAB).Methods Seven children older than 3 months with transposition of great arteries with intact ventricular septum (TGA) were enrolled,they received pulmonary artery banding (PAB group).Eight body surface area matched healthy children were severed as control group.Using the STI technique,the rotation curves at apex and base were analyzed.ResultsAll the patients discharged eventually.The intraoperative LV/RV systolic pressure ratio in PAB group was (0.32 ± 0.04):1.There were no differences in ejection fraction and wall thickness between control and PAB group.However,the end diastolic diameter and end diastolic volume in PAB group was significantly reduced.Compared with the control group,the hypoplasia of LV in PAB group was associated with an extended time to peak basal rotation,and furthermore,the basal and global torsion was significantly reduced by 3 times.ConclusionsSTI showed local rotation and global torsion might be thevaluable predictor to evaluate the regressed and the development of LV peri-PAB procedure for the older children with TGA.
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BACKGROUND: The Damus-Kaye-Stansel (DKS) procedure is a proximal MPA-ascending aorta anastomosis used to relieve systemic ventricular outflow tract obstructions (SVOTO) and pulmonary hypertension. The purpose of this study was to review the indications and outcomes of the DKS procedure, including the DKS pathway and semilunar valve function. MATERIAL AND METHOD: A retrospective review of 28 patients who underwent a DKS procedure between May 1994 and April 2006 was performed. The median age at operation was 5.3 months (13 days~38.1 months) and body weight was 5.0 kg (2.9~13.5 kg). Preoperative pressure gradients were 25.3+/-15.7 mmHg (10~60 mmHg). Eighteen patients underwent a preliminary pulmonary artery banding as an initial palliation. Preoperative main diagnoses were double outlet right ventricle in 9 patients, double inlet left ventricle with ventriculoarterial discordance in 6, another functional univentricular heart in 5, Criss-cross heart in 4, complete atrioventricular septal defect in 3, and hypoplastic left heart variant in 1. DKS techniques included end-to-side anastomosis with patch augmentation in 14 patients, classical end-to-side anastomosis in 6, Lamberti method (double-barrel) in 3, and others in 5. The bidirectional cavopulmonary shunt and Fontan procedure were concomitantly performed in 6 and 2 patients, respectively. RESULT: There were 4 hospital deaths (14.3%), and 3 late deaths (12.5%) with a follow-up duration of 62.7+/-38.9 months (3.3~128.1 months). Kaplan-Meier estimated actuarial survival was 71.9%+/-9.3% at 10 years. Multivariate analysis showed right ventricle type single ventricle (hazard ratio=13.960, p=0.004) and the DKS procedure as initial operation (hazard ratio=6.767, p=0.042) as significant mortality risk factors. Four patients underwent staged biventricular repair and 13 received Fontan completion. No SVOTO was detected after the procedure by either cardiac catheterization or echocardiography except in one patient. There was no semiulnar valve regurgitation (>Gr II) or semilunar valve-related reoperation, but one patient (3.6%) who underwent classical end-to-side anastomosis needed reoperation for pulmonary artery stenosis caused by compression of the enlarged DKS pathway. The freedom from reoperation for the DKS pathway and semilunar valve was 87.5% at 10 years after operation. CONCLUSION: The DKS procedure can improve the management of SVOTO, and facilitate the selected patients who are high risk for biventricular repair just after birth to undergo successful staged biventricular repair. Preliminary pulmonary artery banding is a safe and effective procedure that improves the likelihood of successful DKS by decreasing pulmonary vascular resistance. The long-term outcome of the DKS procedure for semilunar valve function, DKS pathway, and relief of SVOTO is satisfactory.
Subject(s)
Humans , Aorta , Aorta, Thoracic , Bays , Body Weight , Cardiac Catheterization , Cardiac Catheters , Constriction, Pathologic , Crisscross Heart , Double Outlet Right Ventricle , Echocardiography , Follow-Up Studies , Fontan Procedure , Freedom , Heart , Heart Ventricles , Hypertension, Pulmonary , Mitral Valve Insufficiency , Multivariate Analysis , Parturition , Pulmonary Artery , Reoperation , Retrospective Studies , Risk Factors , Vascular ResistanceABSTRACT
BACKGROUND: Pulmonary artery banding (PAB)in the functional univentricular heart (UVH)is a palliative procedure for staging toward the Fontan procedure;however,it is known to be a risk factor. MATERIALS AND METHOD: The records of all 37 patients with functional UVHs who underwent surgical palliation using PAB between September 1989 and August 1999 were reviewed retrospectively.We investigated the aortic arch obstruction,the development and progression of subaortic stenosis after PAB,and risk factor of mortality according to surgical method. RESULT: In 37 neonates and infants with single ventricular physiology,aortic arch obstruction was combined in 7.There were 6 early deaths (16.2%)after PAB and 3 late deaths (8.1%)after Fontan operation.The actuarial overall survival including early mortality at 3 and 5 years were 8 0 .7+/-6.6%,72.2 +/-8.2% respectively. Among 31 patients who survived PAB,27 patients (87.1%)could become candidates for Fontan operation;22 patients(71.0%)completed Fontan operation with 3 deaths and 5 were waiting bidirectional cavopulmonary shunt(BCPS)or Fontan operation (follow-up mean 4.5 year,minimal 2 year). Subaortic stenosis developed in 8 patients after PAB (8/29,27.6%);3 cases in the patients without arch anomaly (3/22,13.6%)and 5 in those with arch anomal y (5/7,71.4%).The subaortic stenosis was managed with Damus-Kaye-Stansel procedure (DKS)in 6 patients without operative mortality and conal septum resection in 2 without long-term survivor. Analysis of risk factors established that aortic arch obstruction was strongly associated with subaortic stenosis (p<0.001).The only risk factor of late mortality was Fontan procedure without staged palliation by BCPS (p=0.001). CONCLUSION: PAB is effective as an initial palliative step in functional UVH.And the high risk group of patients with aortic obstruction can undergo effective short-term PAB as an initial palliative step,with subsequent DKS for subaortic stenosis.This strategy,initial PAB and careful surveillance,and early relief of subaortic stenosis can maintain acceptable anatomy and hemodynamics for later Fontan procedures.
Subject(s)
Humans , Infant , Infant, Newborn , Aorta, Thoracic , Constriction, Pathologic , Fontan Procedure , Heart , Hemodynamics , Mortality , Pulmonary Artery , Risk Factors , SurvivorsABSTRACT
BACKGROUND: Constriction or banding of the pulmonary artery to create pulmonary artery stenosis is a palliative procedure designed to limit pulmonary blood flow in congenital cardiac malformation with unrestricted left to right shunt. Activation of sensory endings such as the arterial baroreceptors results in an inhibitory endings in the heart. The purpose of this study is to test the hypothesis that acute pulmonary artery constriction(PAC) results in an enhanced cardiopulmonary inhibition of the arterial baroreflex. METHODS: Baroreflex control of renal sympathetic nerve activity(RSNA) were examined in rabbits before and during reversible PAC. New Zealand white rabbits were instrumented with an occluder around the main pulmonary artery, a right ventricular catheter, femoral artery and venous catheters, and recording electrodes around renal sympathetic nerves. Baroreflex mediated changes in RSNA were monitored during decreases and increases in mean arterial pressure. RESULTS: Acute PAC produced significant([<0.05) changes in mean arterial pressure(76.3+/-1.9 vs. 59.8+/-3.0mmHg), right ventricular systolic pressure(23.1+/-4.2 vs. 42.3+/-7.4mmHg), and resting RSNA(100 vs. 71+/-6.3%). The effect of acute PAC on the arterial baroreflex was characterized by decreases in RSNA range(103.0+/-1.3 vs. 83.8+/-3.8%) and gain (-3.5+/-0.2 vs. -2.6+/-0.2). CONCLUSION: Acute PAC significantly attenuates arterial baroreflex control of RSNA in rabbits. The attenuated arterial baroreflex regulation of RSNA may be result of an enhanced inhibitory influence from activated cardiac receptors.