Evaluation of pulmonary artery banding in the setting of ventricular septal defects and severely elevated pulmonary vascular resistance.
BACKGROUND
Children with pulmonary hypertension secondary to large left-to-right, post-tricuspid valve shunts can eventually have severe and/or irreversible pulmonary vascular disease, yielding them inoperable for conventional surgery. It has been shown, however, that unloading of the pulmonary hypertension can result in remodeling of the pulmonary vasculature and, thus, improvement of the pulmonary hypertension.


METHODS
This study explored whether such patients might experience a significant reduction in pulmonary vascular resistance (PVR) after pulmonary artery band (PAB) placement. Pulmonary hypertension hemodynamics were evaluated by cardiac catheterization in 4 patients with pulmonary hypertension secondary to nonrestrictive left-to-right, post-tricuspid valve shunts before and after PAB placement. Two patients with severe pulmonary hypertension who were considered high risk for conventional surgery benefited from PAB placement with a significant reduction in their PVR, permitting subsequent complete intracardiac repair.


RESULTS
The medium-term follow-up for these 2 patients demonstrated good outcomes. The PVR failed to improve after PAB placement in the remaining 2 patients, leading to medical therapy for pulmonary hypertension. There was 1 late death, presumably related to pulmonary hypertension. Current practice provides 3 relatively unattractive options for patients with severe pulmonary hypertension secondary to nonrestrictive left-to-right, post-tricuspid valve shunts: transplantation, high-risk intracardiac repair, or palliative medical therapy.


CONCLUSIONS
Our study suggests that a staged approach with initial PAB placement can be considered for select patients with large left-to-right, post-tricuspid valve shunts and high PVR prior to committing them to other high-risk therapeutic options.
Khan
Sadaf A
SA
Division of Pediatric Cardiology, Mount Sinai School of Medicine, New York, NY 10029, USA.
Gelb
Bruce D
BD
Nguyen
Khanh H
KH
D000293:Adolescent; D006328:Cardiac Catheterization; D002648:Child; D015897:Comorbidity; D003250:Constriction; D003326:Coronary Circulation; D017809:Fatal Outcome; D005260:Female; D006345:Heart Septal Defects, Ventricular / Q000453:epidemiology* / Q000503:physiopathology / Q000601:surgery; D006439:Hemodynamics; D006801:Humans; D006976:Hypertension, Pulmonary / Q000188:drug therapy / Q000453:epidemiology* / Q000503:physiopathology / Q000628:therapy*; D008297:Male; D009543:Nifedipine / Q000627:therapeutic use; D019736:Prostheses and Implants; D012189:Retrospective Studies; D014655:Vascular Resistance; D014665:Vasodilator Agents / Q000627:therapeutic use
D014665:Vasodilator Agents; D009543:Nifedipine