PULMONARY-ARTERY BANDING FOR THE TREATMEN T OF UNIVENTRICULAR HEART -RESULTS AND THERAPEUTIC IMPLICATIONS FOR CAVOPULMONARY CONNECTIONS

Eighty-six children under one year of age with univentricular hearts a ssociated with increased pulmonary flow underwent pulmonary artery ban ding as the first stage of palliative therapy. Fifteen patients also h ad treatment of coarctation of the aorta at the same time and an atria l septal defect was treated in 13 patients. Twenty-seven patients unde rwent a Fontan procedure secondarily. The mean follow-up was 42.6 +/- 45,5 months; 8 patients were lost to follow-up. Twenty-three patients died during the whole of the study period. The global actuarial surviv al rate was 69.6 +/- 5% at 5 years. The 3 year survival rate was 56 +/ - 12% in patients with anatomical right ventricles compared with 74.4 +/- 5.7% and 69.5 +/- 7.3% at 3 and 5 years respectively in those with anatomical left ventricles (p < 0.01). The presence of coarctation of the aorta reduced the 5 year actuarial survival rate to 25.4 +/- 12.8 % (p < 0.01). Subaortic stenosis either at the time of initial present ation or occurring during pulmonary banding was associated with a 5 ye ar survival of 58.3 +/- 13.7% (p < 0.01). Uni- and multivariate analys is demonstrated poor prognostic rick factors. On univariate analysis, they were the residual mean pulmonary pressures after banding, coarcta tion of the aorta, subaortic stenosis and a restrictive atrial septal defect. Independent risk factors on multivariate analysis were the res idual pulmonary pressures after banding, coarctation of the aorta, the necessity of operation in the neonatal period and the need for reoper ation for reason other than for a cavopulmonary connection. The feasib ility of a Fontan procedure was reduced when sub-aortic stenosis was o bserved at any time. Only 17.5% of patients were free of reoperation d uring this study for whom banding remained the only palliative procedu re. In conclusion, a programme of cavopulmonary connection should be e nvisaged from the initial presentation of these patients. The differen t stages of treatment with this objective in mind should aim to preser ve myocardial function and keep pulmonary resistances low. Therefore, pulmonary artery banding should be rejected in cases with coarctation of the aorta and/or subaortic stenosis. Similarly, early conversion wi th a Glenn type bidirectional anastomosis allows adaptation of myocard ial function for a secondary total cavopulmonary connection.