British Heart Journal, I973, 35, 65i-656.

Pulmonary artery banding and subsequent repairin ventricular septal defect

R. G Patel, H. N. C. Ihenacho, L. D. Abrams, R. Astley, C. G. Parsons,K. D. Roberts, and S. P. SinghFrom The Children's Hospital, Ladywood Middleway, Ladywood, Birmingham

Fifty-four patients required pulmonary artery banding in the period January 1966 to April i972 for isolatedor complicated ventricular septal defects. The main indication for the procedure was intractable congestivecardiac failure not responding to medical therapy. There was a I2 per cent mortality. Complications resultingfrom the operation are recorded. Twenty of these children have subsequently undergone repair of the ventricularseptal defect and reconstruction of the pulmonary artery with a mortality of 30 per cent. To reduce these highrisks, the second operation should be performed as early as possible, before secondary changes have resultedfrom the presence of the band. In the near future the operative mortality should be more acceptable whenprimary repair is undertaken in infants under the age of 6 months, using profound hypothermia. Primaryrepair is certainly preferable to banding for patients over 6 months of age.

During infancy, ventricular septal defects with exces-sive pulmonary blood flow and pulmonary hyperten-sion can posea considerable problem in management.Such cases have a high morbidity and appre-ciable mortality with medical therapy (Coleman,I965; Ritter et al., I965; Nadas, I967; HofEman,I968). However, surgical repair of ventricular septaldefects with severe pulmonary hypertension, especi-ally in the first six months, also has a high mortality(Hallman, Cooley, and Bloodwell, I966; Sigmann,Stem, and Sloan, I967). Hence, pulmonary arterybanding may be preferred in these selected cases.It can reduce excessive blood flow and prevent thedevelopment of pulmonary vascular disease (Mullerand Dammann, I952; Craig and Sirak, I963;Goldblatt et al., I965). Subsequent repair of theventricular septal defect and reconstruction of thepulmonary artery may then be done after two orthree years (Hallman et al., I966; Stark et al., I970).

First operation: pulmonary artery bandingClinical material Fifty-four infants with a ventricu-lar septal defect were treated by pulmonary artery band-ing between January I966 and April 1972. All thesepatients presented with dyspnoea and failure to thrive;they had rib recession in inspiration and many of thebabies had to be fed by gastric tube. Operation wasundertaken when heart failure would not respond tointensive medical treatment with digoxin, diuretics,and oxygen, and when survival appeared to be unlikelyReceived 13 November I972.

without operation. This applied especially to infantsunder the age of 6 months (43 patients). Two childrenwere over i year old at the time of banding.

Forty of these patients were investigated fully by car-diac catheterization before operation; in iI the diagnosiswas confirmed by venous angiocardiography alone; andin 3 pulmonary artery banding was carried out as anemergency measure without investigation because theinfants' condition was so precarious. Cardiac catheter-ization was performed under general anaesthesia withthe patients breathing 40 per cent oxygen. In all casespulmonary blood flow was at least twice systemic flowand the systolic peak pressure in the pulmonary arterywas more than two-thirds of systemic arterial pressure.The effect of alpha blockade, for example with tolazoline,was not assessed.

Surgical procedure Pulmonary artery banding wascarried out through a left lateral thoracotomy and anylon tape o03 cm wide was used for the ligature. On 3occasions the band was secured by additional stitches.If a persistent ductus arteriosus and/or coarctation ofthe aorta were present in addition to the septal defectthese were corrected and the pulmonary artery was ban-ded only when this failed to reduce the pulmonary arterypressure sufficiently. The correct tension on the bandwas judged in most cases by recording the pulmonaryartery pressure distal to the constriction. When thiscould not be done the pulmonary artery was narrowedto between one-third and one-half of the original di-ameter - just short of causing cardiac arrest.

Postoperative care Intensive treatnent was usuallyneeded. Digoxin was continued and antibiotics were

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652 Patel, Ihenacho, Abrams, Astley, Parsons, Roberts, and Singh

given for at least a week. Blood pH, PCO2, and basewere measured by the Astrup method using capillarysamples unless an indwelling arterial line had been leftin position. To aid ventilation after operation an endo-tracheal tube was left in situ for 24 to 48 hours, but in I2infants the lungs were so stiff that assisted ventilationhad to be continued for a longer period. The endotrachealtube was replaced by a tracheostomy in 4 children whohad to be ventilated for more than a week.

Deaths The nature of the cardiovascular lesion is setout in Table i. Seven children died. One death occurredtwo years after operation when the ligature cut throughthe pulmonary artery. At necropsy the ventricular septaldefect was found to be almost closed and there was an

intrapulmonary aneurysm at the site of the band. Sixpatients died soon after operation and three of thesechildren had complicating cardiovascular anomalies. Ababy with coexisting mitral incompetence failed to re-spond to banding and died after two days. By contrasta baby with complicating aortic coarctation improvedafter operation but progress was not maintained; pul-monary vascular congestion was again more severe andit was concluded that the band had worked loose. Theinfant died when the band was replaced. The third babyhad a persistent ductus arteriosus in addition to theventricular septal defect.Three patients who died had anomalies in other sys-

tems - hydrocephalus, cleft palate and hare lip, andphenotype Turner's syndrome with normal chromo-somes - but there is no reason to suppose that thesewere responsible for death.The mortality rate bore no relation to the age at

operation (Fig. i) or to the child's weight at operation(Fig. 2).

Survivors Clinical picture The follow-up period isfrom 3 months to 6 years. The average weight of patientswhen dealt with surgically was 4-27 kg. After bandingclinical improvement was usually rapid and there wasa characteristic growth spurt (Menahem and Venables,1972).

Haemodynamic findings Before banding most patientshad a large left-to-right shunt and pulmonary hyper-

12

11109.

6 80

u 7-0 6

.0

E 4-z 3-

2

1 2Age (mth)

a Dead

3 4 5 6 7 8 >10

FIG. I Distribution by age at pulmonary arterybanding for ventricular septal defect. The hospitalmortality is shown.

20Dead

18

U14-

0 12 -

E

6

2-3 4 5 7

Weight (kg)

FIG. 2 Distribution by weight at pulmonary artery

banding for ventricular septal defect. The hospitalmortality is shown.

TABLE i Association between cardiac lesion and mortality from pulmonary artery banding (54 cases)

Cardiac lesion Total no. Patients Deaths Mortalityof patients survived per cent

Early Late

Large VSD 32 29 3 9.4VSD+PDA IO 9 I - IOVSD +PDA+ coarctation of aorta 3 I I 66VSD + coarctation of aorta - - -VSD+ASD 7 7 - -VSD + mitral incompetence I - I tOO

Total 54 47 6 I 12-9

fi--FAMEEML--

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Pulmonary artery banding and subsequent repair in ventricular septal defects 653

tension. Three patients had multiple ventricular septaldefects. Cardiac catheterization has been repeated in 31survivors. In 24 of these it was possible to enter the distalpulmonary artery and to assess the degree of constrictionby a withdrawal trace. The shunt had decreased in allthe 3 I patients: in 4 it was from right to left, in I8 it wasbidirectional, in 6 it was from left to right, and in 3 noshunt could be demonstrated. Confirmation that thedefect had closed spontaneously was obtained when 2of the patients had their second operation.The position of the band was demonstrated by biplane

cineangiocardiography with contrast medium injectedinto the right ventricle. The band had slipped up to thebifurcation of the pulmonary artery in 7 patients (Fig. 3and 4) and in 2 others the band had distorted the pul-monary valve, obstructing right ventricular outflow andcausing infundibular hypertrophy.

Second operation: removal of band andclosure of septal defect

The mean interval between first and second operationswas 3-4 years. In all, 20 patients have undergone thesecond operation, the approach being through a mediansternotomy incision and using a pump oxygenator andmoderate hypothermia. The ligature was found at vary-ing positions along the pulmonary artery trunk. It couldbe removed easily in only 2 cases. Deformity ofthe arterywas such that I0 patients required arterioplasty - alongitudinal incision made at the site of constrictionbeing sutured transversely - and in 8 other cases thearterial lumen had to be enlarged with a pericardial patch.An extensive pericardial graft reconstruction was neces-sary for a child with severe narrowing at the origin ofthe left pulmonary artery, the result of a band which hadslipped. Ventricular septal defects were closed through aright ventriculotomy in all cases except one which wasclosed through a right atrium. The surgeon felt it de-sirable to do an infundibulectomy in I0 patients to en-sure that outflow obstruction was relieved. Two patientshad atrial septal defects of the ostium secundum typeand these were closed surgically during the course ofthe operation.

Postoperative care The postoperative course wasoften stormy, as it was after the first operation. Ventila-tion was required, usually for 24 to 72 hours, but 8patients had to be ventilated for a longer period. A 'lowcardiac output state' occurred frequently and requiredthe inotropic effects of adrenaline and isoprenaline.One patient developed complete atrioventricular blockand has a permanent artificial pacemaker. Nodal rhythmwas observed in 6 cases but reverted to sinus rhythmspontaneously within 4 days.

Deaths Six patients died. Dysrhythmia contributedto death in 2, I of whom developed atrial tachycardiawith block on the fifth postoperative day, and the otherbeing readmitted 4 days after discharge from hospitalbecause of atrial tachycardia. Neither patient had re-ceived digitalis in the preceding 4 days. Three childrendied in a 'low cardiac output state' which failed to

FIG. 3 and 4 Angiocardiogram showing constrictionof the main pulmonary artery branches (arrow) due toa slipped ligature.

respond to pressor drugs and fluid replacement. Post-operative bleeding probably contributed to one of thesedeaths. The sixth child died a few hours after operationand at necropsy was found to have severe pulmonaryvascular changes; this patient had failed to maintain theinitial improvement which followed banding and correc-tive surgery was undertaken three months after the firstoperation. Cardiac catheterization (Case I0, Table 2)had shown a pressure gradient across the band but araised pressure in the distal pulmonary artery.

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654 Patel, Ihenacho, Abrams, Astley, Parsons, Roberts, and Singh

TABLE 2 Haemodynamicfindings and method of reconstruction in 20 patients

Case Age when Age at Main pulm. Systolic pressures after Systolic pressure after Shunt VSDNo. pulmonary corrective artery systolic banding (mmHg) corrective operation diameter

artery operation pressure before (mmHg) (mm)banded (yr) banding(mth) (mmHg) RV PA RV PA

I 2-5 4 50 74 I4 90 40 Bidirectional 202 I5 4 68 85 i8 35 25 Bidirectional 4

3 2 3 - 90 65 Iuo R-L Io

4 8 4 5 55 82 I5 60 50 L-R 17

5 2-5 I-7 50 75 20 -6 4-5 4 65 70 35 40 25 - 5

7 8 3 70 84 80 25 Bidirectional 5

8 2.5 4-8 40 82 I5 60 40 -9 I0 6-8 60 70 35 60 45 L-R 20

I0 7 0-8 70 80 30 60 20 Bidirectional io

II 4 3i4 70 8o 30 45 35 L-R I5

I2 3 5 6 75 90 28 - L-R II3 2.5 2-6 50 90 40 60 30 Bidirectional i5

I4 5 3-8 70 94 25 Bidirectional ISI5 6 2-8 55 98 24 40 40 Bidirectional 25

i6 2 I.4 58 95 30 60 30 R-L I3I7 7 4.8 60 II5 35 50 30 Bidirectional i5

i8 8 4-8 75 78 20 40 20 Bidirectional i5

I9 i8 4.6 65 85 40 30 Bidirectional 2520 4 6 55 80 30 60 40 L-R 20

Survivors Clinicalfeatures Fourteen patients who sur-vived the second operation have remained well over aperiod ranging from 2 months to 2 years. This includesthe child who has complete atrioventricular block whichhas needed a permanent artificial pacemaker. Threepatients have murmurs suggesting that there is a smallresidual septal defect, but no other disability.

Haemodynamic findings Table 2 gives the data ob-tained from cardiac catheterization before operation andfrom direct measurements taken in the theatre aftercompletion of the operation. As might be expected,right ventricular pressure tended to fall and pulmonaryartery pressure tended to rise as a result of correction.However, in 2 cases (Cases 4 and 8) pulmonary arterypressure, which had been controlled while the band wasin position, rose to prebanding levels after operation andin 4 others (Cases I, 9, I5, 20) it rose to levels whichwere above the normal. This appeared to bear no rela-tion to the age at banding or to the initial pulmonaryartery pressure, but all these patients had large ventricu-lar septal defects. It can also be seen from Table 2 that

4 patients (Cases I, 7, 13, i6) were left with a pressuregradient of more than 30 mmHg across the right ven-tricular outflow tract, and 2 of these died.

DiscussionIf an infant with a large left-to-right shunt througha ventricular septal defect, a high pulmonary arterypressure, and heart failure, fails to respond to inten-sive medical therapy, the chance of survival is re-mote without surgical treatment (Coleman, I965;Nadas, I967). The risks of primary repair of theseptal defect have been reduced by using profoundhypothermia (Kyoto technique, Hikasa et al., I967)and Barratt Boyes has exploited this method withexcellent results (Barratt Boyes et al., 197I). How-ever, the operative risks in infants under the age of6 months are high: DuShane, Weidman, and Ritter(1972) quote a mortality of 22 per cent for severecases in this age group compared with 4 to 5 percent in older infants. Though we have included in

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Pulmonary artery banding and subsequent repair in ventricular septal defects 655

Method of closure Reconstruction of Resultof VSD PA and outflow

tract

Teflon patch Pericardial patch Alive and wellSuture Arterioplasty, Alive and well

infundibulectomyTeflon patch Pericardial patch, Alive and well

infundibulectomyPericardial patch Pericardial patch Alive and well

(heart block)Band removed Alive and well

Suture Arterioplasty, Alive and wellinfundibulectomy

Suture Arterioplasty, Diedinfundibulectomy

Pericardial patch Alive and wellTeflon patch Infundibulectomy, Died

pericardial patchTeflon patch Arterioplasty, Died

infundibulectomyTeflon Pericardial patch, Alive and well

LPATeflon patch Arterioplasty Alive and wellTeflon patch Pericardial patch, Alive and well

infundibulectomySuture Arterioplasty Alive and wellTeflon patch Arterioplasty, Alive and well

infundibulectomyTeflon patch Pericardial patch DiedTeflon patch Infundibulectomy, Alive and well

arterioplastyPericardial Infundibulectomy, Died

arterioplastyTeflon patch Band removed easily DiedTeflon patch Arterioplasty Alive and well

this series of cases some children whose pulmonaryartery was banded after the age of 6 months it isnow our practice to advise primary repair for suchpatients.Pulmonary artery banding has been shown to

reduce pulmonary blood flow and to prevent or

cause regression of pulmonary vascular changes(Dammann et al., I96I) but this review of our ex-

perience indicates that results are often by no means

satisfactory. Seven children out of 54 died after thefirst operation and the risk did not appear to belinked with the child's age or weight at the time ofoperation, though the presence of cardiac lesions inaddition to the ventricular septal defect probablyincreased the risk. Only 20 children have yet hadthe second operation and 6 of these have died.Table 3 summarizes the experience from a numberof centres and leads to the conclusion that ourpresent overall mortality of 24 per cent (for bothoperations) will increase to 30 per cent or more bythe time that all patients have had their second

operation. Removal of the band, repair of the septaldefect, and reconstruction of the pulmonary arteryand the right ventricular outflow tract may presentserious technical problemsMost of the complications of pulmonary artery

banding described in this paper have been reportedby other workers. The band may cut through thewall of the pulmonary artery irrespective of the

TABLE 3 Comparison of mortality in publishedseries of repair of ventricular septal defects andpulmonary artery reconstruction after pulmonaryartery banding

Author's name and No. of No. of Per centyear patients deaths mortality

Dammann et al. (I96I) II 4 36.3Hailman et al. (I966) 14 I 7.1Stark et al. (I969) 2I 6 28-5Hunt et al. (I97I) 24 3 I2.5Coleman et al. (1972) I5 4 28-2Present series (I972) 20 6 30

material used for the ligature (Rohmer, Brom, andNauta, i967; Stark et al., I970). Migration of theband may constrict the lumen of the main pulmon-ary artery branches or may lead to deformity andthickening of the pulmonary valve cusps. There maybe infundibular muscle hypertrophy (Hunt et al.,197i), and the obstruction may be sufficient toreverse the shunt. Infundibulectomy may be neces-sary as part of the final surgical repair, but, even so,it may prove impossible to eliminate the gradientbetween the right ventricle and pulmonary artery.We hope that a pressure gradient of 30 mmHg willnot affect the ultimate prognosis and that, since thecause of the infundibular hypertrophy has beenremoved, the gradient will diminish gradually overthe years.We believe that three quite large ventricular septal

defects have closed spontaneously after banding.This has been reported by Hunt et al. (I97I) andby Verel, Chandrasekhar, and Taylor (I97i). Thereduction in left-to-right shunt noted after bandingmay be due in part to a closing septal defect (Cole-man et al., I972) but it can be seen from Table 2that banding will diminish or reverse a shunt evenwhen a large septal defect is present.

Postoperative dysrhythmias were usually of shortduration. Complete atrioventricular block requiringpermanent artificial pacing is an unfortunate com-plication which might have occurred after primaryrepair; banding cannot be blamed. Two patientshad atrial tachycardia shortly after the first opera-tion: both died; neither was taking digitalis at thetime.

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656 Patel, Ihenacho, Abrams, Astley, Parsons, Roberts, and Singh

Banding certainly lowered pulmonary artery pres-sure (Table 2) but it did not necessarily controlpulmonary hypertension in the long term. Wethought that the band might have loosened in twocases, an experience recorded by Stark and hiscolleagues in i969 and by Menahem and Venablesin I972. Both these children died, one after a secondbanding operation and one after corrective surgery.In the second of these the band was tight enough toproduce a pressure gradient, but at necropsy severepulmonary vascular changes were demonstrable.Two children in whom pulmonary artery pressurewas well controlled by the band had undoubted pul-monary hypertension when the band was removedand the ventricular septal defect closed, and fourother patients had similar but less obvious changes.Admittedly postoperative pressures were recordeddirectly before the child left the operating theatrebut the findings are disturbing especially in view ofreports from the Mayo Clinic that pulmonary vascu-lar changes may be progressive despite satisfactoryclosure of the ventricular septal defect (DuShane etal., I972). If in fact these are examples of infantswhose pulmonary vascular bed failed to respond toa reduction of pressure and flow after effective pul-monary artery banding, it cannot be assumed thatthe response would have been any more favourableif the initial operation had been a primary repairof the septal defect.

It is uncertain what the eventual outcome will bein these cases. Though pressure may fall as timepasses it is also possible that the condition willdeteriorate. The one child whose cardiac catheter-ization has been repeated some months after thesecond operation had normal pressures and noshunt, but further long-term follow-up studies willbe undertaken. We have found it impossible topredict which cases will do well after banding.Neither age, nor weight, nor the degree of pulmon-ary hypertension at the time of the first operationappears to affect the outcome.

ReferencesBarratt-Boyes, B. G., Simpson, M., Seelye, E., and Neutz, J.

(I97I). Intracardiac surgery in neonates and infants usingprofound hypothermia (Kyoto technique). In VI WorldCongress of Cardiology, I970. Cardiovascular Research,P. 7I.

Coleman, E. N. (I965). Serious congenital heart disease ininfancy. British Heart Journal, 27, 42.

Coleman, E. N., Reid, J. M., Barclay, R. S., and Stevenson,J. G. (1972). Ventricular septal defect repair after pulmon-ary artery banding. British Heart_Journal, 34, I34.

Craig, T. V., and Sirak, H. D. (I963). Pulmonary artery band-ing; an analysis of 38 cases. J7ournal of Thoracic and Cardio-vascular Surgery, 45, 599.

Dammann, J. F., McEachen, J. A., Thompson, W. M.,Smith, R., and Muller, W. H., Jr. (I96I). The regressionof pulmonary vascular disease after the creation of pul-monary stenosis. J7ournal of Thoracic and CardiovascularSurgery, 42, 722.

DuShane, J. W., Weidman, W. H., and Ritter, D. G. (1972).Influence of the natural history of large ventricular septaldefects on management of patients. Birth Defects: OriginalArticle Series, Vol. 8, pp. 63-68. Published for the NationalFoundation -March of Dimes, New York, by Williamsand Wilkins, Baltimore.

Goldblatt, A., Bernhard, W. F., Nadas, A. S., and Gross,R. E. (I965). Pulmonary artery banding. Indications andresults in infants and children. Circulation, 32, 172.

Hallman, G. L., Cooley, D. A., and Bloodwell, R. D. (I966).Two-stage surgical treatment of ventricular septal defect;results of pulmonary artery banding in infants and sub-sequent open-heart repair. Journal of Thoracic and Cardio-vascular Surgery, 52, 476.

Hikasa, Y., Shirotani, H., Satornura, K., Muraoka, R., Abe,K., Tsushimi, K., Yokota, Y., Mibi, S., Kawai, J., Mori,A., Okamoto, Y., Koie, H., Ban, T., Kanzaki, Y., Yokota,M., Mori, C., Kamiya, T., Tamura, T., Nishii, A., andAsawa, Y. (I967). Open heart surgery in infants with anaid of hypothermic anesthesia. Archiv fur japanischeChirurgie, 36, 495.

Hoffman, J. I. E. (I968). Natural history of congenital heartdisease; problems in its assessment with special referenceto ventricular septal defects. Circulation, 37, 97.

Hunt, C. E., Formanek, G., Levine, M. A., Castaneda, A.,and Moller, J. H. (197I). Banding of the pulmonary artery.Results in iii children. Circulation, 43, 395.

Menahem, S., and Venables, A. W. (I972). Pulmonary arterybanding in isolated or complicated ventricular septal de-fects. Results and effects on growth. British Heart3Journal,34, 87.

Muller, W. H., Jr., and Dammann, J. F., Jr. (I952). Thetreatment of certain congenital malformations of the heartby the creation of pulmonary stenosis to reduce pulmonaryhypertension and excessive pulmonary blood flow. Surgery,Gynecology and Obstetrics, 95, 213.

Nadas, A. S. (I967). Management of infants with ventricularseptal defect. A controversy. Pediatrics, 39, I.

Ritter, D. G., Feldt, R. H., Weidman, W. H., and DuShane,J. W. (I965). Ventricular septal defect. Circulation, 32,Suppl. 3, p. 42.

Rohmer, J., Brom, A. G., and Nauta, J. (I967). Bands insidethe pulmonary artery. A complication of the Dammann-Muller procedure. Annals of Thoracic Surgery, 3, 449.

Sigmann, J. M., Stem, A. M., and Sloan, H. E. (I967). Earlysurgical correction of large ventricular septal defects.Pediatrics, 39, 4.

Stark, J., Aberdeen, E., Waterston, D. J., Bonham-Carter,R. E., and Tynan, M. (I969). Pulmonary artery constric-tion (banding): a report of I46 cases. Surgery, 65, 8o8.

Stark, J., Tynan, M., Aberdeen, E., Waterston, D. J., Bon-ham-Carter, R. E., Graham, G. R., and Somerville, J.(1970). Repair of intracardiac defects after previous con-striction (banding) of the pulmonary artery. Surgery, 67,536.

Verel, D., Chandrasekhar, K. P., and Taylor, D. G. (97I).Spontaneous closure of ventricular septal defect afterbanding of pulmonary artery. British Heart Journal, 33,854.

Requests for reprints to Dr. R. G. Patel, The Children'sHospital, Ladywood Middleway, Birmingham Bi6 8ET.

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