Pulmonary artery debanding Guido Oppido, Carlo Pace Napoleone, Simone Turci, Emanuela Angeli and Gaetano Gargiulo* Paediatric Cardiac Surgery Unit, S. Orsola-Malpighi Hospital, University of Bologna Medical School, Bologna, Italy; * Corresponding author. Tel: +39-51-6363156; fax: +39-51-6363157; e-mail: gaetano.gargiulo@aosp.bo.it (G. Gargiulo). Received 26 September 2011; received in revised form 14 December 2011; accepted 27 December 2011 Summary Pulmonary artery banding is a simple palliative surgical procedure for congenital heart defects with left-to-right shunt or complete mixing and pulmonary over-circulation. Even though indication for pulmonary artery banding has been sensibly reduced, since early reparative surgery has been proved superior to palliation and a staged approach, an increasing support for pulmonary banding has been raised in the last two decades by new indications such as left ventricular retraining, in the late arterial switch operation for complete transposition of the great arteries or before the double-switch operation in congenitally corrected transposition. Along with the increasing interest raised by the new indications and the consequently more difuse use of banding, debanding has become an important surgical issue. Debanding is usually performed several months after palliation along with the repair of the cardiac malformations; otherwise, it can be done progressively or partially to further delay surgery and let the patient grow. Occasionally, after pulmonary artery banding, a spontane- ous resolution of the underlying cardiac malformation can occur; however, a debanding procedure is in any case necessary. Keywords: Pulmonary artery debanding • Pulmonary over-circulation • Pulmonary banding INTRODUCTION Since pulmonary artery banding was introduced in 1952 [1], it has been utilized for many diferent congenital heart lesions [2,3] to reduce pulmonary overlow and improve cardiac symptoms, pre- venting heart failure and pulmonary hypertension. Over the last 20 years, the use of pulmonary artery banding has been sensibly reduced, since early reparative surgery, when feasi- ble, has been proved safer and more efective compared with a staged approach [4]. Nevertheless, pulmonary artery banding is nowadays still in common clinical use in selected cases such as: ‘functionally ’ single-ventricle hearts with unrestricted pulmonary blood low, multiple ventricular septal defects (VSDs), complex complete atrio-ventricular canal, complex coarctation, aortic arch obstruction with VSD, or when left ventricular retraining is needed in cases such as a late-referred transposition of the great arteries (TGA) [5] or congenitally corrected transposition of the great arteries (ccTGA) [6]. New indications for pulmonary artery banding have been con- sidered in hypoplastic left heart syndrome along with ductus arte- riosus stenting during a hybrid palliative procedure. A series of potential complications along with diiculties in determining the optimal tightness with the consequent risk of early or even multiple reoperations [7] make pulmonary artery banding a far from banal procedure that also carries a quite high mortality [8]. Each time a pulmonary artery band is positioned, a debanding procedure should always be expected at the time of cardiac mal- formation repair or when the underlying cardiac lesion has spon- taneously resolved. Moreover, in selected cases, when waiting for the ideal time for complete correction is required, a partial and progressive debanding or band loosening can be indicated even though the patient is exposed to an adjunctive open-chest procedure. The high rate of reoperations, along with the opportunity to adjust the band’s tightness and the need for removing the band and consequently reconstructing the pulmonary artery at the time of repair, have prompted surgeons to look for some alterna- tive debanding techniques, such as reabsorbable material bands [9,10], catheter debanding systems [11] or telemetric adjustable devices [12], with the aim of reducing the number of open-chest procedures. SURGICAL TECHNIQUE Pulmonary artery banding is a simple palliative technique to counteract pulmonary over-circulation in some congenital heart diseases. Usually, a 3–4 mm wide band is positioned around the main pulmonary artery to reduce its cross-sectional area oppos- ing an increased resistance to the right ventricular outlow and therefore reducing left-to-right shunt or reducing pulmonary low and increasing systemic low in ‘single-ventricle’ hearts. The debanding techniques proposed are multiple, depending on the underlying heart malformation, the time expected for the next surgical step, the prospect of spontaneous resolution of the malformation and the need to repeatedly adjust the band‘s tightness. (i) In the case of classic open-chest debanding, a 4-mm Dacron band is positioned and secured and progressively tightened with stitches or with metallic clips at the time of the pulmonary banding procedure. At the time of repair, after starting the cardiopulmonary bypass, the band around the pulmonary artery is identiied, starting from the metallic doi:10.1093/mmcts/mms009 published online 15 May 2012 © The Author 2012. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.