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Efficacy of pulmonary artery banding in infants with complete atrioventricular canal
Insights
Pulmonary artery banding (PAB) offers a safer initial surgical option for infants with complete atrioventricular (AV) canal, reducing mortality compared to immediate total correction.
Area of Science:
- Pediatric Cardiology
- Congenital Heart Disease Surgery
- Critical Care Medicine
Background:
- Complete atrioventricular (AV) canal in infants under 1 year is associated with high operative mortality for total correction.
- Pulmonary artery banding (PAB) has been considered contraindicated in cases with severe mitral insufficiency or large left-to-right shunts.
Purpose of the Study:
- To evaluate the safety and efficacy of pulmonary artery banding (PAB) as an initial palliative procedure for infants with complete AV canal and congestive heart failure.
- To challenge previous assumptions regarding contraindications for PAB in specific congenital heart defects.
Main Methods:
- Retrospective analysis of 21 consecutive infants with complete AV canal who underwent PAB at a mean age of 3.9 months.
- PAB was performed with or without concomitant procedures like patent ductus arteriosus ligation or coarctation repair.
- Cardiac catheterization was repeated post-PAB to assess pulmonary hemodynamics.
Main Results:
- A low in-hospital mortality of 4.7% (1/21) was observed, with one patient requiring band readjustment.
- Significant reduction in pulmonary hypertension and flow was noted post-PAB, with no increase in pulmonary vascular resistance.
- All infants showed symptomatic improvement, and four later underwent successful total correction.
Conclusions:
- Pulmonary artery banding (PAB) is a rational and safer alternative to immediate total correction for symptomatic infants with complete AV canal.
- PAB can be safely performed regardless of mitral valve competency, offering a viable palliative strategy.
- This approach is particularly beneficial when high-risk anatomical variants are identified pre-operatively.
Abstract:
Total correction in infants less than 1 year old with complete atrioventricular (AV) canal carries a significant operative mortality. However, past reports suggest that the alternative palliative procedure, pulmonary artery banding (PAB), may be contraindicated in the presence of severe mitral insufficiency and/or a large left ventricular to right atrial shunt. Contrary to these previous reports, we report the results in 21 consecutive patients with congestive heart failure who underwent PAB at a mean age of 3.9 +/- 2.8 months and at a weight of 3.6 +/- 0.9 kg. (17/21 less than 6 months). Regardless of mitral valve competency, PAB was performed in conjunction with ligation of a patent ductus arteriosus (11 patients) and coarctation repair (two patients) with one death secondary to gastrointestinal bleeding (4.7% in-hospital mortality); one patient required early band readjustment because of hypoxemia. Repeat cardiac catheterization in 10 patients performed 4 to 41 months after PAB showed significant reduction in pulmonary hypertension and flow with no change in pulmonary vascular resistance. All infants were symptomatically improved after PAB and four have undergone successful total correction. Previous reports since 1977 indicate a significantly higher risk for total repair of complete A V canal before 1 year of age (36/147, 24%) than the risk for PAB in this series (p less than .05). Therefore, we believe that PAB is a rational alternative to total repair as the initial surgical treatment for symptomatic infants with complete A V canal, particularly when anatomic variants known to increase operative risk are recognized before cardiotomy.