Physiology-guided bilateral pulmonary artery banding in high-risk neonates: early hemodynamic and perfusion outcomes

Balancing pulmonary and systemic blood flow remains one of the most critical challenges in the management of high-risk neonates with ductal-dependent circulation, particularly in the presence of low birth weight, sepsis, shock, restrictive interatrial communication, or complex congenital cardiac anatomy. Bilateral pulmonary artery banding (biPAB) is frequently employed as an initial stabilizing strategy to control pulmonary overcirculation; however, optimal band tightness remains largely experience-based, and uniform band sizing may be associated with variable physiological responses. This study evaluated whether a physiology-guided, individualized approach to biPAB is associated with more favorable early hemodynamic and perfusion profiles compared with a conventional uniform banding strategy.

This retrospective, two-center cohort study included critically ill neonates undergoing emergency bilateral pulmonary artery banding for ductal-dependent systemic and/or coronary circulation. Patients were managed using either a conventional uniform banding technique or a physiology-guided strategy based on body weight-adjusted branch pulmonary artery z-scores targeting an approximate -2 z-score diameter. Early postoperative assessment included serial measurements of systemic arterial pressure, arterial oxygen saturation, end-tidal carbon dioxide (etCO₂), Doppler-derived pulmonary artery flow velocities, and regional cerebral and somatic oxygenation assessed by near-infrared spectroscopy.

A total of 44 high-risk neonates underwent bilateral pulmonary artery banding (conventional banding, n = 20; physiology-guided banding, n = 24). Both strategies were associated with increases in systemic arterial pressure. Compared with the conventional group, the physiology-guided group demonstrated greater and more consistent reductions in etCO₂, together with higher Doppler-derived pulmonary artery flow velocities. Postoperative arterial oxygen saturation was lower in the physiology-guided group, while differences between arterial oxygen saturation and regional cerebral and somatic oxygenation were smaller. Absolute regional oxygenation values remained stable in both groups. Early postoperative and interstage mortality did not differ between strategies.

In high-risk neonates with ductal-dependent circulation, a physiology-guided bilateral pulmonary artery banding strategy based on weight-adjusted pulmonary artery z-scores was associated with more predictable modulation of pulmonary blood flow and more consistent early hemodynamic and perfusion profiles, without an observed increase in early or interstage mortality. These findings support the feasibility of integrating individualized, physiology-driven principles and multimodal physiological monitoring into neonatal pulmonary artery banding strategies.