pulmonary artery banding 최 창 휴최 창 휴 2009 25 th ktcs 밴딩 교약술 띠조임 목조임

Pulmonary Artery Banding

최 창 휴2009 25th KTCS

밴딩

교약술

띠조임

목조임

Pulmonary Artery Banding

최 창 휴2009 25th KTCS

PAB (Pulmonary Artery Banding)

• Palliative surgical therapy

• Initial surgical intervention for L-R shunting and pulmonary

overcirculation

• Early definitive intracardiac repair has largely replaced palliation with PAB

2009 25th KTCS

History

• Muller and Dammann,UCLA (1951)

• “Creation of pulmonary stenosis" in 5mo

VSD

• Single ventricle or large VSD

• Reduce PA size by 2/3 ► PBF 50% ▼

- Muller and Dammann. Ann Surg

1952 -

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L-R shunt ► pulmonary blood flow (PBF) ▲

► pulmonary edema and CHF in the neonate

► fixed pulmonary hypertension

PAB ► PBF and pulmonary artery pressure ▼

► reduces the shunt volume► improves cardiac output

Role

2009 25th KTCS

Indication I

Pulmonary overcirculation and L-R shunt who require reduction of PBF as a staged approach to definitive repair

Multiple muscular VSDs : "Swiss cheese"

Single or multiple VSDs with CoA or IAA

Single ventricle, increased PBF in the neonate

Unbalanced AVC, potential for 2-ventricle repair

Cardiac defects that require homograft conduit

(eg, d-TGA with PS requiring Rastelli-type repair)

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TGA who require training of the LV as a staged approach to the ASO

d-TGA, older than 1 monthd-TG, previous Mustard or Senning l-TGA, for doubled switch procedure

Indication II

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Techique :Band Material

e-PTFE umbilical tape silastic material coatingsilk woven Dacron striporlonsilicone band with radiopaque markerpolydioxanone ribbon (absorbable) (ATS

2001)...

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Trusler’s rule,1984

- circumference 20 + 1 mm for each kg of Bwt : VSD w/o bidirectional shunting

- circumference 24 + 1 mm for each kg of Bwt

: VSD w/ bidirectional shunting

- circumference 22 + 1 mm for each kg of Bwt

: Fontan

Techique : Adjustment Techique

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• Distal PAP:- 1/3 to 1/2 of SAP, acceptable SaO2

- 30 to 50% of SAP, SaO2 85 to 90% on FiO2 0.5

- 50% of SAP, SaO2 75 to 85% on FiO2 0.6 in SV

- systolic PAP to 50% of its previous level- mean PAP 20 to 30 mmHg- systolic PAP 30 to 40 mmHg

• SAP 10 mmHg , bradycardia (-), hypoxemia (-) for 10 min., SaO2 80%


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Age <3 mo, intracardiac mixing(+) ► Tight banding : PAP 1/3 of SAP, acceptable SaO2 80%

Age >3 mo, intracardiac mixing(?) ventriculoarterial discordance, potential SAS, severe GA size discrepancy ► Loose banding : PAP 1/2 of SAP, SAP 10 mmHg

- intraop TEE, loosening if myocardial dysfuction after recovery of myocardial fuction, additional tightening for 5-10 day


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• Median sternotomy:- more precise band placement & anchoring

• Thoracotomy:- minimal adhesions- left lateral thoracotomy, 4th ICS - left ant. mini-thoracotomy, 2nd or 3rd ICS

Techique : Exposure

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Techique : Exposure

RPA - more acute angle : risk of impingement

MPA - dilatation & thin wall

: risk of tearing

Median sternotomy

if intracardiac procedures requiring CPB

in malposed or transposed GA

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Techique : Exposure

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Techique :

placed away from PV to avoid dysplastic changes &

distortion2009 25th KTCS

Techique :

fixation to two opposite sites of PA wall to avoid poorly positioned band & band

migration

Sequential tightening

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Techique :

“Too loose" over subsequent weeks and months

: Later resorption & remodeling of the arterial wall

► restore a greater internal corss-sectional area

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Techique :

Incisional technique, Laks, 1999

more stable band gradient over time

eliminated the complication of band migration distally

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Techique : takedown

Patch angioplasty

Resection & end-to-end anastomosis

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Postop

• Improved hemodynamics and greater LV output often allow for diuresis and the gradual resolution of CHF

• Hypotension, bradycardia, and ischemic EKG changes all indicate an excessive band gradient

• Adjustable PAB is that it allows for rapid loosening of the band with a hemoclip remover in the ICU

• Echo : band tightness, band gradient, band position, and overall cardiac function

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Follow-up

• Pulmonary overcirculation are monitored for 3-6 months

• Undergo more definitive repair of their cardiac defect • Severe right ventricular hypertrophy in response to

PAB should be considered for earlier definitive repair

• LV trainig : serial echo for "readiness" of the LV • LV mass index, ventricular septal geometry. L-R

septal bowing • usually accomplished within 7-10 days

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Band-Related Complications

1. Branch PA stenosis (esp. RPA) 2. PV distortion & thickening PR3. PA erosion & aneurysm4. Ineffectual banding

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Asymmetric vascular markings in CXR

Echo, Scan

Limiting the dissection btw aorta & MPA

Fixing the band

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Devastating when preparation for ASO

Can lead to obstruction of coronary blood flow

Avoided by placement of the band more than 15 mm distal to the pulmonary valve cusps

More important : intraoperative vigilance 2009 25th KTCS

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1. Branch PA stenosis (esp. RPA) 2. PV distortion & thickening PR3. PA erosion & aneurysm 4. Ineffectual banding

Erosion in narrow banding material

Risk of rupture, hemolytic anemia, thrombus

Pseudoaneurysm : d/t local infection & erosion

Urgent surgical intervention

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1. Branch PA stenosis (esp. RPA) 2. PV distortion & thickening PR3. PA erosion & aneurysm

4. Ineffectual banding

Loose band at the original procedure

Later disruption of the band or erosion of the PA

15-20%

Loss of the band murmur and recurrence of CHF after PAB

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Drawbacks

1. Ventricular hypertrophy 2. SAS or BVF narrowing3. Change in the ventricular geometry4. Chance of damaging the PV

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SV with ventriculoarterial discordance (DILV with TGA or Tricuspid atresia with TGA)

In aortic arch anomalies 50%, restrictive bulboventricular foramen(BVF)

PAB may cause rapid progression of SAS

CIx: BVF > 15-20 mmHg, < BVF index 2 ㎠ / ㎡

Damus-Kaye-Stansel(DKS) & shunt

Potential for the development of significant subaortic stenosis(SAS)

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DKS(Damus-Kaye-Stansel) Op

: creation of aorto-pulmonary window, systemic-pulmonary shunt & division of MPA)

UVH(SV) without SAS UVH(SV) with SAS

PAB

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Subaortic stenosis post-PAB

• Adversely affect the outcome of future Fontan procedures

• Ventricular hypertrophy and subendocardial ischemia

• Duration of PAB : independent risk factor • Resection of the obstruction or a DKS procedure • Earlier cavopulmonary connection

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Truncus arteriosus

Type I : very short MPA Type II,III : bilateral PAB is necessary balancing is extremely difficult

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Hypoplastic left heart syndrome (HLHS)

hybrid approach of stenting the ductus arteriosus and bilateral PAB may achieve effective short-term palliation

considered in high-risk patients.

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Outcome and Prognosis

• Mortality rate :complexity of the cardiac defect & the overall condition than with the procedure itself • 25% (1998) ► 3-5%

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PAB Revisited(Muller Jr. Ann Surg 1989)

• 1955 – 1988, retrospective review• n = 170• overall mortality ; 45% • late mortality ; 10% (1% per year )• mortality in SV ; 12% (best result)• actuarial survival rate at 10 y. in SV ; 92%

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• risk factors for survival:- diagnosis (G I 88,8% vs G II, III 64.9%)- time period (early 64.3% vs late 92.5%)- Bwt < 4 kg in early period (37.5% vs 91.7%)

• no risk factors for survival:- CoA, PDA, Bwt < 4 kg in late period, preoperative status, PAP, days of intubation, inotropic support

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PAB: Results and Current Indications (LeBlanc ATS 1987)

Mortality of Pulmonary Artery Banding in theCurrent Era: Recent Mortality of PA Banding

(Takayama ATS,2002)

Group 1 (n 167), 1966 – 1979Group 2 (n 111), 1980 – 1989Group 3 (n 87), 1990 – 2001

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Early Mortality 38% 13.5% 13.8%

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Risk Factor Analysis and Surgical Indications for Pulmonary Artery Banding

(Chang Hyu Choi,KTCS,2005)

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Future

• Adjustable band technique • Intraluminal technique • Percutaneously adjustable,

thoracoscopically implantable • Hydraulic MPA constrictor• Telemetric controled FloWatch-R-PAB

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hydraulic main pulmonary artery occluder

JTCS 2003

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Remote control of pulmonary blood

flow: Initial clinicalExperience

(Corno JTCS 2003)

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“Intraluminal”technique

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• 1990 - 2004, 32 patients median age 40 days, weight 3.5 kg

• Circular patch of woven Dacron graft circular opening (2 to 8 mm in diameter) determined by two factors:

half of the diameter of the aortic annulus

according to the size of the patient 2 - 3 mm for newborns 3 - 4 mm for infants 4 - 5 mm for older children 5 - 8 mm for adults

•In 20 patients, an APW was created simultaneously.

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• Early mortality: 31% (10 patients) 9 of 20 patients (45%) in group 1 (EPAB with APW) 1 of 12 patients (8%) in group2 (EPAB without APW) • No distal pulmonary hypertension, distortion, or band occlusion.

• F/U 22 patients 15.5 years (mean 2.6) -> 6 Late deaths -> 10 debanding and biventricular repair or Fontan procedure

•Endoluminal pulmonary artery banding (EPAB) : consistently effective and durable reduction in PA blood flow with no pulmonary artery distortion.

2009 25th KTCS

Pulmonary Artery Internal Banding

Sejong General Hospital

Choi Chang-Hyu, Kim Woong-Han

Pulmonary artery banding (PAB)

PV distortion & thickening -> PR

Progression of Subaortic stenosis (SAS)

-> Internal PAB ??

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1999.5 – 2003.5 25patients

Age 2.0 ± 2.7month Weight 3.7±1.4 kg

Diagnosis LVOTO CoA & IAA

Functional UVH 12 Cris-cross 3 Unbalanced AVSD 4 DILV or DIRV 4 TA 1

2

11

224

DORV 12 Remote 5 TB 5 SA 2

111

31

TGA 1

25 7 12

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Extended end-to-side anastomosis (EESA)

without circulatory arrest and myocardial ischemia

with regional high-flow perfusion

into the innominate artery and coronary artery

Conal septum Resection

through the MPA-tomy

Perforated Gore-Tex patch

(central opening diameter, 3-4.5 mm)

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Internal PAB (25)

Early Mortality (3)

Late Mortality (2)

F/U loss (2)

BCPS (11)

ASO (3)

Biventricular repair (3)

Waiting Biventricular repair (1)

Waiting Fontan (6)

Fontan (3)

F/U loss (1)

Late Mortality (1)

EESA

EESA c ASO

Debanding c CSR

TAPVR

EEEA

EESA c CSR

EESA

-> BCPS

-> AVVR

EESA c CSR

->BCPS

-> BCPS

EESA c CSR -> BCPS

EESA -> BCPS c CSR

EESA -> DKS c BCPS

m-DKS -> BCPS

EESA -> DKS c m-RBT

-> BCPS

EEEA c CSR -> BCPS

CSR -> BCPS c CSR

CSR -> DKS c BCPS

F/U loss (1)

CSR -> m-DKS

2nd op after 7.1 ± 7.3 month

-> CSR

-> CSR

-> CSR

Conal Septum Resection (CSR)

Preop LVOTO (7) -> CSR (7)

SAS progression after IPAB (8)

-> CSR (6) , DKS (2)

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•Prevent distortion of the pulmonary artery & pulmonic valve

•The central hole provide equal & adequate pulmonary blood flow

•Easier to resect of conal septum through the large PA

•Define Intracardiac morphology for second stage operation

DORV(remote)

-> IPAB (13d)

-> ASO (10m)

cath at 9m

•Relatively low mortality & morbidity

•Effective as an initial palliative procedure in selective case

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Conclusion

• Nowadays PAB is still used as a palliative surgical procedure for congenital heart defects

• SV, LV training in TGA, hybrid approch in HLHS

• Newly technique : adjustable, internal…

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Acquired SAS (after PAB) in SV: Two Mechanisms

• PAB muscular hypertrophy- restriction of the VSD & subaortic area- compliance (as risk factors for successful Fontan hemodynamics)

• PAB volume unloading ventricular geometry changes

cavity & wall thickness compromising systemic pathway

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SAS, UVH, & PAB: an analysis of the course of 43 pts. with UVH by PAB

(Freedom Circulation 1986)

• Jan. 1970 – June 1985• n = 43• PAB in UV and deveolpment of SAS• development of SAS ; 31 (72.1%)• mean age at PAB ; 0.21 y. (1 d. – 1.07 y.)• mean age at SAS ; 2.52 y. (0.05 – 8.07 y.)• LV type, discordant VA connection:

- development of SAS ; 27/32 (84.4%)

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SAS, UVH, & PAB: an analysis of the course of 43 pts. with UVH by PAB

(Freedom Circulation 1986)

• neonates or young infants with actual or potential SAS in UV Norwood type procedure

or graft interposition b/w MPA & dAo. + PAB

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Early Changes in VSD Size & Ventricular Geometry in the Single Left

Ventricle After Volume-Unloading Surgery

(Donofrio JACC 1995)

• n = 18, retrospective review• single left ventricle or TA• volume unloading surgery:

- PAB 6 - hemi-Fontan 11- primary Fontan 1

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Early Changes in VSD Size & Ventricular Geometry in the Single Left

Ventricle After Volume-Unloading Surgery

(Donofrio JACC 1995)

• VSD diminution after VUS or PAB:- occurs early- related to acute alteration in ventr. geometry that accompanies the decrease in ventr. volume (LVEDV)- cavopulmonary connection > PAB

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Subaortic Obstruction and the Fontan Operation

(Freedom ATS 1998)

• DILV, rudimentary RV, discordant VA connection systemic outflow tract obstruction

• congenital or acquired• factors of acquired systemic outflow tract obstr.:

- VSD size- previous PAB- previous volume-unloading surgery

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Subaortic Obstruction and the Fontan Operation

(Freedom ATS 1998)

• staging w/ BCPS & DKS BCPS & VSD enlargement neutralized the factor

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Usefulness of PAB With SV Physiology at Risk for SAS

(Laks Am J Cardio 1996)

• Jan. 1984 – Dec. 1994• n = 26• DILV or TA and TGA• initial PAB (± arch reconstruction)• mean age ; 2.1 ± 1.8 m.• arch anomaly ; 8/26 (31%)

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• SAS (resting) ; 16 (62%)• SAS relief (n = 19):

- DKS (n = 12)- VSD enlargement (n = 8)- alone or in conjnction with Glenn or Fontan

• neonatal DKS: - arch anomaly, critically small VSD, ductal dependent systemic circulation (only Ix.)

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• PAB as an initial palliative step (relative simplicity and low mortality rate)

• subsequent intervention for SAS when it is documented or highly suspected

• acceptable pre-Fontan hemodynamic parameters can be achieved

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Neonatal PAB does not compromise the short-term function of DKS (Daenen Eur J Cardio-thorac Surg 2000)

• 1993 – 1998• n = 13• UVH with TGA & PHT• initial PAB (± CoA repair)• 2nd stage DKS:

- n = 12- mean interval ; 1.1 y. (4 w. – 50 m.)

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• associated procedures at DKS:- Glenn/hemi-Fontan 8- BTS 2- Fontan 1- biventricular repair

1 • 3rd stage Fontan 4• waiting Fontan 7

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• no mortality after 2 & 3rd stage operation

• F/U after DKS:- mean duration ; 2.5 y. (1.3 m. – 4.9 y.)- PR ; G 0 (1) G I (8) G II (3)- AR ; G 0 (6) G I (6)- PG ; no (11) yes (1)- regression of hypertrophy ; all

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• neonatal short-term PAB does not

compromise the function neither of a

DKS connection nor a Fontan repair

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Is PAB Obsolete for TA & DIV & Discordant VA Connection? Role of Aortic Arch Obstruction & Subaortic

Stenosis (Franklin JACC 1990)

• useful predictor of SAS after PAB:- initial BVF/aAo. ratio < 0.8- initial BVF/AV ratio < 1 *

- initial BVF/BSA index < 2 cm2/m2 **

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Is PAB Obsolete for TA & DIV & Discordant VA Connection? Role of Aortic Arch Obstruction & Subaortic

Stenosis (Franklin JACC 1990)

• PAB w/ AAO rapid development of SAS alternative initial surgery, even high risk

• PAB w/o AAO reasonable risk & adequate sized VSD good Fontan candidates

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DKS With Cavopulmonary Connection for SV & SAS(Spray ATS 1993)

• n = 9• SV & TGA ± AAO• neonatal sort-term PAB

DKS + BDG or Fontan • mean age at PAB ; 1 m.• mean age at DKS ; 17 m.

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DKS With Cavopulmonary Connection for SV & SAS(Spray ATS 1993)

• neonatal PAB coupled with planned early debanding, DKS procedure, and cavopulmonary anastomosis is a relatively low-risk course for patients with this complex physiology

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SV with SO in early life: comparison of initial PAB vs Norwood operation

(Tchervenkov Eur J Cardio-thorac Surg 2001)

• Jan. 1987 – July 2000• n = 22• SV and AAO, SAS, or both• two initial surgical approaches:

- G I PAB ± CoA repair 7- G II Norwood type operation 15

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• overall mortality: 32% (7/22)- G I 43%- G II 27% (no mortality since 1995, n = 8)

• no late mortality• Fontan ; 9 BDG ; 4 • SAS &/or AAO:

- G I 4/7 pts. 8 reinterventions- G II 1/15 pts. 1 supravalvar AS repair



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• PAB ± CoA repair:- high mortality - high reoperation rate for SAS or AAO

• Norwood type operation:- high mortality in early period- now excellent outcome emerge as the procedure of choice



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Does PAB Affect PV Function After the DKS Operation?

(Mavroudis ATS 1998)

• 1982 – 1996, retrospective review• n = 15• DKS after initial PAB: incidence of PI

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• Diagnosis:- DILV 6- TGA with VSD 4- TB anomaly 2- TA 2- c-TGA 1

• median age at PAB ; 7 d.• median duration of PAB ; 7 m.



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• PAB take-down d/t:- cyanosis - band pressure gradient (PG) - age appropriate for Fontan- PG across subaortic area



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• no operative mortality • late death ; 1 (6.7%) (d/t conduit

obstruction)• mean F/U duration ; 7.5 y. (1 – 15 y.)• PI (n = 2):

- mild 1- moderate 1 (trivial before PAB)

• AI (n = 4): - required AV closure 3



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• prior PAB does not appear to cause significant PI in patients for DKS

• the incidence of significant PI after DKS operation is relatively low



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Modified DKS Procedure for SV, SAS, and AO in Neonates and Infants: Midterm Results and Techniques for Avoiding Circulatory

Arrest(Hanley JTCS 1997)

• DKS should be done:- potential SAS (+)- significant semilunar valve regurgitation (-)

• abandon DKS: - arch obstruction & aAo. diameter < 4 mm arch repair w/ circulatory arrest or Norwood procedure

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• PAB should be done:- only when no reasonable BVF obstruction- BVF area > AV area- BVF index > 2 cm2/m2

- potential SAS (-)• BVF enlargement should be avoid

whenever possible



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• modified DKS: - effective primary palliation for SV & SAS ± arch obstruction- results are encouraging in neonates- arch repair can be achieved w/o circulatory arrest to the brain



2009 25th KTCS

pulmonary artery banding 최 창 휴최 창 휴 2009 25 th ktcs 밴딩 교약술 띠조임 목조임

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