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Univentricular Pulmonary Artery Banding: How Tight is Tight Enough for Successful Progress?
Servet Ergün1, Erman Çilsal2, Serhat Bahadır Genç3
1Department of Pediatric Cardiovascular Surgery, Erzurum Regional Training and Research Hospital, Üniversite, Çat Yolu Cd, 25240, Yakutiye/Erzurum, Turkey. drservetergun41@gmail.com.
Insights
Successful pulmonary artery banding (PAB) in single-ventricle anomalies improves Fontan completion rates and long-term survival. Achieving adequate PAB targets is crucial for better outcomes in pediatric cardiac surgery.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Surgery
- Single Ventricle Physiology
Background:
- Pulmonary artery banding (PAB) is a palliative procedure for single-ventricle anomalies with unrestricted pulmonary blood flow.
- The Fontan procedure is a complex, multi-stage surgical approach for single-ventricle physiology.
- Optimizing PAB is critical for successful Fontan completion and improved long-term outcomes.
Purpose of the Study:
- To evaluate the impact of intraoperative and pre-discharge parameters following PAB on the successful completion of Fontan procedures.
- To identify factors associated with progression towards Fontan completion versus failure-to-progress.
Main Methods:
- Retrospective analysis of 50 consecutive patients with single-ventricle anomalies undergoing PAB.
- Patients were categorized into 'successful' (Fontan completion or eligibility) and 'failure-to-progress' groups.
- Comparison of hemodynamic parameters (systolic, mean, and ratio of pulmonary to systemic arterial pressure) and pre-discharge gradients between groups.
Main Results:
- The successful group comprised 68% of patients; the failure-to-progress group was 32%.
- Significant differences were observed in post-PAB systolic, mean, and pressure ratios (P < 0.05).
- Higher pre-discharge gradients were noted in the successful group (60 mm Hg vs. 47.5 mm Hg; P=0.05), with lower mortality (2.9% vs. 31.2%; P=0.04).
Conclusions:
- Successful PAB, characterized by specific hemodynamic targets, is associated with improved long-term survival and Fontan completion.
- Close monitoring and timely re-banding are essential when PAB targets are not met to prevent adverse outcomes.
Abstract:
We investigated the effects of intraoperative parameters measured during pulmonary artery banding operations and pre-discharge parameters on the completion of Fontan procedures. Fifty consecutive patients with single-ventricle anomalies and unrestricted pulmonary blood flow who underwent a PAB operation in and were discharged from our hospital were retrospectively analyzed. Patients who underwent a Fontan operation, a Glenn shunt operation, or who were eligible for a Fontan procedure were defined as the "successful group." Patients who needed rebanding prior to a bidirectional Glenn shunt, patients who were not eligible for a Glenn shunt, and those underwent a takedown due to high pulmonary arterial pressure after implantation of a Glenn shunt were defined as the "failure-to-progress group." The successful group included 34 (68%) patients and the failure-to-progress group included 16 (32%) patients. The median age was 2 months (IQR 1-4 months). There was a statistically significant difference between the groups in terms of systolic pulmonary arterial pressure, mean pulmonary arterial pressure, and pulmonary arterial pressure/systemic arterial pressure after PAB (P = 0.01, 0.03, and 0.03, respectively). While the median gradient before discharge was 60 mm Hg (IQR 50-70 mm Hg) in the successful group, it was 47.5 mm Hg (IQR 45-63.7 mm Hg) in the failure-to-progress group (P = 0.05). Mortality was observed in one (2.9%) patient in the successful group and five (31.2%) patients in the failure-to-progress group (P = 0.04). Successful pulmonary arterial banding increases long-term survival. Adequate targets should be determined, efforts should be made to achieve these targets, and patients should be followed up closely in terms of rebanding when the targets are not reached.
