Modified pulmonary artery banding: A novel strategy for balancing pulmonary blood flow with transposed great arteries

Abstract

Objective: To study the outcomes of a novel modified pulmonary artery banding (mPAB) technique used for staged repair of a subset of patients with complex transposition physiology.Methods: A total of 13 patients who underwent mPAB during their staged repair (biventricular repair [BVR], n ¼ 6) or palliation (1-1/2 repair, n ¼ 1; univentricular repair [UVR], n ¼ 6) from 2004 to 2020 were studied retrospectively. A restrictive interposition graft was used to reconstruct the main PA between the pulmonary root and the distal pulmonary confluence, functioning as a mPAB. Twelve of the 13 patients (92.3%) underwent a concurrent arterial switch operation (ASO), of which 6 were palliative ASOs for 1-1/2 repair (n ¼ 1) or UVR (n ¼ 5). Patient weight and cardiac anatomy determined the size of interposition graft.Results: The disease spectrum included dextro transposition of the great arteries (d-TGA) with multiple ventricular septal defects (VSDs) (n ¼ 4), Taussig-Bing anomaly (n ¼ 3), d-TGA with VSD and hypoplastic right ventricle (RV) (n ¼ 3), double-inlet left ventricle with l-TGA (n ¼ 2), and congenitally corrected TGA with double-outlet RV (n ¼ 1). The Lecompte procedure was performed in 10 patients. Predischarge echocardiography revealed a band gradient of 61 mm Hg (interquartile range [IQR], 40-90 mm Hg) for BVR/1-1/2 ventricular repair (n ¼ 7) and 49 mm Hg (IQR, 37-61 mm Hg) for UVR (n ¼ 6). Survival was 100% at a median follow-up of 3.7 years (IQR, 2.6-4.0 years). Conclusions:The mPAB technique is effective and reproducible for staged BVR or UVR for patients with TGA. It effectively regulates pulmonary blood flow, may reduce neopulmonary root distortion, and eliminates complications associated with band migration in standard PAB. (JTCVS Techniques 2021;-:1-10) Sketch diagram depicting differences in standard and modified pulmonary artery banding.

Commentary: Another way to skin a cat, hardly ever

“…In the current issue of the Journal, Salve and colleagues 1 present a small case series of 13 patients who underwent a novel modified pulmonary artery band (PAB) technique as part of initial palliation of complex cardiac anomalies (years 2004-2020). In their modified PAB technique, a restrictive interposition graft was used to reconstruct the main pulmonary artery between the pulmonary root and the distal pulmonary confluence, functioning as a modified PAB.…”

“…The authors chose this modified technique of interposition graft as it is more likely to provide controlled and more predictable restriction of the pulmonary blood flow than traditional PAB, with lower risk of dislodgement and consequent distortion of the pulmonary valve or pulmonary artery branches. 1 What the authors from Australia are describing in this report is: (1) an alternative management strategy performing concomitant arterial switch operation and PAB, plus/ minus aortic arch repair as initial palliation and (2) an alternative technique of interposition graft rather than traditional PAB. For me, I feel that the modified PAB technique and the management strategy should be addressed separately.…”