Pulmonary artery banding (PAB) is a simple surgical technique to reduce pulmonary overcirculation in some congenital heart disease.The heart is separated into 4 chambers. Deoxygenated blood enters into the right chambers of the heart and continues through the pulmonary arteries to be oxygenated in the lungs. Oxygenated blood returns into the left side of the heart and out to the rest of the body, known as the systemic circulation. In congenital heart defects such as ventricular septal defects (VSD) and Atrioventricular septal defects (AVSD), there may be one or multiple holes in the walls separating adjacent chambers. This causes left-to-right shunting of blood as oxygenated blood can flow back to the right side of the heart, resulting in a mixture of oxygenated and deoxygenated blood. Increased amounts of blood on the right side of the heart cause an excess of blood flow into the lungs (pulmonary circulation) and increased pulmonary resistance due to the build up of pressure.
The goal of PAB is to reduce pulmonary artery pressure and excess pulmonary blood flow. PAB involves the insertion of a band around the pulmonary artery to reduce blood flow into the lungs. A variety of banding materials are used; one commonly used material is polytetrafluoroethylene.The band is wrapped around the main pulmonary artery and fixed into place. Once inserted, the band is tightened, narrowing the diameter of the pulmonary artery to reduce blood flow to the lungs and reduce pulmonary artery pressure. PAB followed by later repair is a common surgical alternative when early definitive repair is high-risk.
A surgically created connection between a systemic artery and the pulmonary artery (PA) is termed a systemic-to-pulmonary artery shunt or, more commonly, a BT shunt.The systemic to pulmonary shunt procedure is a temporary procedure performed in children who are not getting enough blood to the lungs for full oxygenation (blue babies).The typical diagnosis associated with this procedure used to be tetralogy of Fallot, although now most of these young patients undergo complete correction early in life. Inova pediatric cardiac surgeons currently use the shunt procedure in complex defects such as tricuspid atresia or pulmonary atresia.
Cavo Pulmonary Shunt (Glenn Shunt) or The Hemi-Fontan Operation
As the children grow, they will require a more permanent supply of blood to their lungs than earlier surgical procedures can provide. A Cavo Pulmonary Connection is normally performed between three and nine months of age.
The aim of this operation is to redirect the flow of blue blood (deoxygenated blood) to the lungs by attaching the upper body vein (Superior Vena Cava) directly on to the lung artery (Pulmonary Artery). The Gore-Tex shunt that was inserted at the last operation will be taken away.
In some centres the stump of the lower body vein (Inferior Vena Cava) is attached to the base of the lung artery (Pulmonary Artery). This is known as the Hemi-Fontan. Although blood does not flow through this attachment at this time, it prepares the child for the completion of a Fontan at Stage Three.
These operations have fewer risks than the first stage but it is important to talk with the medical team to find out the risks for your child.
he Fontan procedure, or Fontan/Kreutzer procedure, is a palliative surgical procedure used in children with complex congenital heart defects. It involves diverting the venous blood from the right atrium to the pulmonary arteries without passing through the morphologic right ventricle.
The Fontan procedure has more recently been used in pediatric situations where an infant only has a single effective ventricle, either due to a heart valve defect (e.g. tricuspid or pulmonary atresia), an abnormality of the pumping ability of the heart (e.g. hypoplastic left heart syndrome or hypoplastic right heart syndrome), or a complex congenital heart disease where a bi-ventricular repair is impossible or inadvisable.
Children with hypoplastic left heart syndrome have a single effective ventricle supplying blood to the lungs and the body (either from birth or after an initial surgery e.g. Norwood procedure). They are delicately balanced between inadequate blood supply to the lungs (causing cyanosis) and oversupply to the lungs (causing heart failure). In addition, the single ventricle is doing nearly twice the expected amount of work because it has to pump blood for both lungs and body. As a result, these children can have trouble gaining weight and are also vulnerable to decompensation in the face of otherwise minor illnesses (even a common cold). Sometimes medications (e.g. diuretics) can help them through this stage.
Therefore, when either they are large enough, and if the pressure in the pulmonary arteries is low enough, these children are referred for the Fontan procedure commonly after 2 years of life.
There are three different types of Fontan procedure:
1. Atriopulmonary connection (the original) Described by Fontan and Kreutzer.
2. Intracardiac total cavopulmonary connection (lateral tunnel)
3. Extracardiac total cavopulmonary connection
Congenital heart disease (CHD) is the most common congenital disorder in newborns. There are no published data on the occurrence of congenital heart disease in Kerala. However there is general agreement among health workers that it follows a similar pattern all over the world in different geographies. The reported prevalence of CHD at birth ranges from 6 to 13 per 1000 live births. On an average, 8 children are born with congenital heart defects for every 1000 live births in India. Variation is primarily due to the use of different methods to detect CHD (fetal echocardiography versus postnatal referral to a cardiac center). Deriving from the crude birth rate, it…
keep readingCongenital heart disease (congenital heart defect) is an abnormality in your heart’s structure that you’re born with. Although congenital heart disease is often considered a childhood condition, advances in surgical treatment mean most babies who once died of congenital heart disease survive well into adulthood. While medical advances have improved, many adults with congenital heart disease may not be getting proper follow-up care. If you had a congenital heart defect repaired as an infant, you likely still need care as an adult. Symptoms Symptoms or signs of congenital heart disease may not show up until later in life. They may recur years after you’ve had treatment for a heart defect.…
keep readingMinimally invasive heart surgery (also called keyhole surgery) is performed through small incisions, sometimes using specialized surgical instruments. The incision used for minimally invasive heart surgery is about 3 to 4 inches instead of the 6- to 8-inch incision required for traditional surgery. The traditional heart surgery procedure Open heart surgery is typically done through a vertical cut placed over the middle of the chest, including full division of the breastbone.While most patients tolerate this well, it can take around 12 weeks or more before the wound is completely healed. This can seriously delay a return to normal activities. These days, it is often possible to avoid such invasive options…
keep readingabout Dr sajan koshy
Pediatric Cardiac Surgeon
Dr Sajan Koshy MS MCh is currently heading the unit of Paediatric & Congenital heart surgery at Aster Medicity. Prior to joining Aster, he was working as senior consultant and head of the department of paediatric cardiac surgery at MIMS Calicut. He started his professional career from alleppey medical college in 1988. He also functioned as a co- convener in first and second symposia on perioperative care of congenital heart disease held in Kochi in the year 2002 and 2004 respectively & as the scientific committee chairman for the national CME of cardio thoracic surgery held at Calicut in September 2007. He has Conducted many lectures in all the districts of North Kerala for the benefit of medical professional bodies to create awareness about congenital heart disease.
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