Pulmonary Artery Banding — Procedure Guide, Recovery & Risks | MyMedicPlus

Pulmonary artery banding (PAB) is a palliative cardiac surgical procedure in which a constricting band is placed around the main pulmonary artery to reduce pulmonary blood flow and protect the pulmonary vascular bed from excessive pressure and volume overload. It is used in neonates and infants with large left-to-right shunt defects — most commonly large ventricular septal defects (VSD), atrioventricular septal defects (AVSD), or truncus arteriosus — when definitive corrective surgery carries prohibitively high risk due to prematurity, low birth weight, concurrent non-cardiac illness, or complex anatomy. PAB is a temporising measure, not a curative procedure: it buys time to allow the infant to grow, other medical conditions to stabilise, and the surgical team to plan definitive intracardiac repair. The band is removed and the underlying defect corrected in a planned operation typically 3–12 months later. Pulmonary artery banding (PAB) is a palliative cardiac surgical procedure that reduces excessive pulmonary blood flow in infants with congenital heart defects causing left-to-right shunting — particularly ventricular septal defects (VSD), atrioventricular septal defects (AVSD), and complex single-ventricle circulations — when definitive repair is not immediately feasible. By narrowing the main pulmonary artery with a band (polytetrafluoroethylene tape, silicone band, or umbilical tape), pulmonary artery pressure and blood flow are reduced, preventing pulmonary hypertension, protecting the pulmonary vascular bed, and allowing the infant to grow before definitive repair. PAB is a staging procedure that buys time for the infant to improve organ function, gain weight, and reach optimal operative size for complete repair or Fontan completion. Modern surgical techniques and neonatal intensive care have made primary complete repair feasible for most defects in developed centres, reducing the frequency of PAB, though it remains essential in specific scenarios including multiple VSDs (swiss cheese septum), complex AVSD in Down syndrome, and deliberate preparation for biventricular repair in single-ventricle hearts.

PAB is indicated in infants with haemodynamically significant large left-to-right shunt defects who are at unacceptably high risk for primary corrective surgery. Specific indications include very low birth weight (under 2.5 kg) with large VSD or AVSD causing heart failure and failure to thrive, multiple VSDs (Swiss cheese septum) where the anatomy precludes direct closure, association with other complex congenital anomalies requiring staged management (e.g., heterotaxy with AVSD), concurrent severe non-cardiac illness (sepsis, necrotising enterocolitis), truncus arteriosus with severe haemodynamic compromise in a sick neonate, or centres where complete neonatal repair is not available. PAB is also used to train the left ventricle for arterial switch operation in patients with late-presenting transposition of the great arteries where the left ventricle has decompressed. Patients with adequate cardiac size and anatomy suitable for primary repair are offered corrective surgery directly without banding at experienced congenital cardiac centres.

PAB is performed under general anaesthesia via a left anterolateral thoracotomy (chest incision), without cardiopulmonary bypass — a significant advantage in small or sick neonates. The pericardium is opened to expose the main pulmonary artery. A band material — typically a 2–4 mm strip of Gore-Tex, silicone tape, or Teflon — is passed around the pulmonary artery and tightened incrementally. The correct degree of constriction is judged by intraoperative pressure monitoring: the goal is to reduce pulmonary artery systolic pressure to approximately 25–50% of systemic pressure (a ratio known as Qp:Qs approaching 1:1), while maintaining adequate systemic cardiac output. Oxygen saturations and distal pulmonary pressures guide band tightening. Clips or sutures secure the band in position. The chest is closed over a small drainage tube. At the planned definitive repair operation, the band is removed, the pulmonary artery repaired at the band site, and the underlying cardiac defect corrected under cardiopulmonary bypass. Surgery is performed under general anaesthesia via left lateral thoracotomy or median sternotomy without cardiopulmonary bypass. The main pulmonary artery is encircled with polytetrafluoroethylene tape, umbilical tape, or a silicone band. Band tension is adjusted to achieve a pulmonary artery distal pressure of 30–50% systemic and oxygen saturation of 85–95% in room air — calibrated using transcutaneous oximetry and intracardiac pressure measurement. The band is fixed with sutures to the adventitia to prevent distal migration. Operative time is 1–2 hours. Median sternotomy is preferred when subsequent staged repairs via the same access are planned.

Pulmonary artery banding successfully reduces pulmonary hypertension and heart failure symptoms in 85–90% of appropriately selected patients, allowing the infant to gain weight and recover from concurrent medical problems before definitive surgery. Without PAB, large left-to-right shunts expose the pulmonary vascular bed to high pressure and flow, leading to irreversible pulmonary vascular obstructive disease (Eisenmenger syndrome) within 12–18 months, which forecloses surgical repair. PAB therefore protects operability. In centres experienced in the staged palliation approach, overall survival from banding through to completed definitive repair is 80–90%. At high-volume paediatric cardiac centres, primary complete repair (without PAB) has become possible for most lesions including large VSDs and AVSDs in neonates with acceptable outcomes, and PAB is reserved for genuinely complex or high-risk cases.

Operative mortality for PAB is 2–5% in current practice, influenced primarily by the severity of the underlying cardiac anatomy and the infant's pre-operative condition. Band migration or band erosion into the pulmonary artery wall can cause distortion of the vessel and complicate removal at the time of corrective surgery. Over-tightening results in excessive right ventricular pressure overload (supra-systemic pulmonary resistance), causing right heart failure; under-tightening fails to adequately protect the pulmonary vascular bed. Band position may shift as the infant grows, requiring either surgical repositioning or early progression to complete repair. Pulmonary artery distortion at the band site requires reconstruction at the time of complete repair. Post-operative complications include pleural effusion, chylothorax from thoracic duct injury, wound infection, arrhythmias, and diaphragmatic injury. Echocardiographic monitoring is performed weekly to assess adequacy of banding.

Following PAB, the infant is transferred to the paediatric intensive care unit for mechanical ventilation and haemodynamic monitoring for 24–72 hours. Extubation is achieved when haemodynamic stability and adequate respiratory function are confirmed. Post-operative echocardiography is performed to assess band position, pulmonary artery pressure, and ventricular function. Most infants are discharged in 7–14 days. Oral diuretics and ACE inhibitors manage residual cardiac failure symptoms during the period of palliation. Nasogastric or oral high-calorie feeding supports weight gain. Serial outpatient echocardiography every 4–6 weeks monitors pulmonary artery pressures and band position. Definitive corrective surgery is planned at 3–12 months depending on the underlying lesion, the infant's weight gain, and clinical stability. After complete repair, the band material is removed and pulmonary artery reconstruction performed, with lifelong cardiology follow-up for the underlying congenital heart disease.