Precise Adjustment of a Band on the Main Pulmonary Artery

Dear Editor

Banding of the main pulmonary artery remains an important palliative step in some children with congenital defects, especially when a Fontan type of repair may be considered. Over three years, we have modifed our technique in order to allow precise adjustment of the band. The proximal half of the main pulmonary artery is dissected and encircled with a 3- or 4 mm wide Teflon band. Attention is paid that the band lies flat on the artery and does not get rolled on itself. Both arms of the band are pulled upward, and a clip is slipped down and applied once the desired constriction of the pulmonary is obtained. Systemic and pulmonary pressure and arterial saturation are measured. If the band needs be tightened further, another clip is applied below the first one. When the correct tightening is achieved, a third clip is applied above to secure the banding (Fig. [1]). Two stitches of polypropylene 6-0 are used to secure the band on the proximal part of the pulmonary artery. The two arms of the band are cut 10 to 15 mm above the Clips and loosely fixed onto the lateral wall of the adjacent ascending aorta. Subsequently, an reoperation, the arms of the band placed on the ascending aorta are spread apart, and lead with minimal dissection to the pulmonary artery. The band and the fibrotic tissue that surrounds it are removed.

We used this technique on 10 neonates, 3 with tricuspid atresia, 3 with large ventricular septal defect and aortic coarctation, 2 with double-inlet left ventricle, 1 with double-outlet right ventricle, and 1 with unbalanced atrio-ventricular canal. 5 were reoperated for a definitive repair and 5 for a staged Fontan operation. Migration of the band toward the bifurcation did not occur. The pulmonary pressure was well controlled in all patients, especially those considered for a Fontan repair, where systolic blood pressure was always below 25 mmHg. At reoperation, the arms of the band were easily found on the ascending aorta and rapidly led to the main pulmonary artery. In the 5 patients with bi-ventricular repair and in 1 patient who had a Damus-Kaye-Stansel connection to partially bypass a restrictive bulbo-ventricular foramen, the pulmonary valve functioned without stenosis or insufficiency.

Our experience shows this technique allows fine adjustment of the pulmonary blood flow and pressure, as a progressive tightening of the banding is possible, and the whole width of the band is applied on the pulmonary artery. Bringing the two ends of the band to the side of the ascending aorta further helps regain access to the pulmonary artery in a subsequent operation.