Pulmonary Artery Banding for Ventricular Rehabilitation in Infants With Dilated Cardiomyopathy: Early Results in a Single-Center Experience

Abstract

Background: Pulmonary artery banding (PAB) is reported as an innovative strategy for children with end-stage heart failure (ESHF) to bridge to transplantation or recovery. We report our early experience with PAB to evaluate outcomes, indications, and limitations. Materials and Methods: This is a single-center prospective clinical study, including infants and children admitted for ESHF owing to dilated cardiomyopathy (DCM) with preserved right ventricular function after failure of maximal conventional therapy. All patients underwent perioperative anticongestive medical therapy with ACE inhibitor, beta blocker, and spironolactone. Post-operatively, all patients underwent echocardiographic follow-up to assess myocardial recovery. Results: We selected five patients (four males) who underwent PAB at a median age of 8.6 months (range 3.9-42.2 months), with preoperative ejection fraction (EF) < 30%. Sternal closure was delayed in all. One patient did not improve after PAB and underwent Berlin Heart implantation after 33 days, followed by heart transplant after 13 months. Four patients were discharged home on full anticongestive therapy. However, 2 months after discharge, one patient experienced severe acute heart failure secondary to pneumonia, which required mechanical circulatory support, and the patient underwent a successful heart transplant after 21 days. The remaining three patients are doing well at home, 22.4, 16.9, and 15.4 months after PAB. They all underwent elective percutaneous de-banding, 18.5, 4.8, and 10.7 months after PAB. EF increased from 17.7 ± 8.5% to 63.3 ± 7.6% (p = 0.03), and they have all been delisted. Conclusion: Use of PAB may be an effective alternative to mechanical support in selected infants for bridging to transplant or recovery. Better results seem to occur in patients aged < 12 months. Further experience and research are required to identify responders and non-responders to this approach.

Surgical strategies for the management of end‐stage heart failure in infants and children: A 15‐year experience with a patient‐tailored approach

“…All but one (the most recent) underwent an elective percutaneous procedure for PAB balloon dilatation, after a median of 11 (7‐15) months from surgery, due to progressive RV hypertension and increased (≥moderate) tricuspid regurgitation. Procedures were well tolerated and patients gradually recovered from LV dysfunction, allowing delisting from HT in three cases, without recurrence of heart failure at last follow‐up, as we described elsewhere 31 …”

“…Procedures were well tolerated and patients gradually recovered from LV dysfunction, allowing delisting from HT in three cases, without recurrence of heart failure at last follow-up, as we described elsewhere. 31 Analyzing the outcomes of this group, despite freedom from HT was 66.6% at last follow-up, because PAB strategy failed in two cases, requiring VAD support, survival was not affected since it was 100% at 1-year follow-up and 5-year follow-up (Figure 5). Noticeably, those patients who lastly required HT were the first patients of our experience.…”

“…Exclusion criteria were as follows: biventricular failure, ≥moderate tricuspid regurgitation, pulmonary hypertension (mean pulmonary pressure >25 mm Hg), and associated major congenital heart disease (CHD). The PAB was tightened until we obtained right ventricular pressure increased to 70% of systemic pressure, or until echocardiographic shift of interventricular septum, or TAPSE reduction, or increasing tricuspid regurgitation (as described elsewhere 27,31 ). Patients <10 years and <20 kg, who did not meet PAB inclusion criteria, were managed with either left or biventricular BH. Patients >10 years or ≥20 kg with isolated LV failure underwent placement of intracorporeal Heartware (HVAD).…”

“…30 A recent multicenter study has reported encouraging short and midterm results on a larger cohort. 26,31 Since 2004, we have gradually developed a surgical program for the management of children with ESHF, which has evolved across the years, to provide our patients with the most effective and state-of-the-art alternatives to HT. As new evidences were emerging, we have adopted the most innovative surgical strategies for ESHF, which currently include MCS, and PAB for left ventricular (LV) rehabilitation, as a bridge to HT, or to favor myocardial remodeling and recovery.…”

Current and Future Drug and Device Therapies for Pediatric Heart Failure Patients: Potential Lessons from Adult Trials

“…It has been shown that there is myocyte regeneration after unloading of the dilated LV by mechanical circulatory support in pediatric dilated cardiomyopathy patients with end-stage HF [ 76 ]. The regenerative strategy is the basis of reversible pulmonary artery band (PAB) in infants and young children with dilated cardiomyopathy [ 77 , 78 ]. Application of a reversible PAB for 2–3 months can increase the contractility of LV by ventricle–ventricle interaction as both RV and LV share a common septum.…”