Pulmonary artery banding in dilative cardiomyopathy of young children: review and protocol based on the current knowledge

Abstract

Dilated cardiomyopathy (DCM) is a leading cause of cardiac death in children. Current therapeutic strategies are focused on improving symptoms of congestive heart failure (CHF); the potentials of cardiac regeneration especially in infants and young children are neglected in particular when DCM is classified as "end-stage". Heart transplantation (HTx) serves as the only life-saving option, despite is palliative character with limited survival time. Therapeutic alternatives are strongly needed, but already existing though less used; presupposed, that cardiac dysfunction and its treatment are not reduced to the four components of heart rate (rhythm), myocardial contractility, preload and afterload. A paradigm shift in the treatment of pediatric heart failure can be achieved by modifying ventricular afterload with improving contra-lateral ventricular function. Adverse ventricular-ventricular interactions (VVI) have the potential to harness them for therapeutic benefit. Surgical placement of a pulmonary artery banding (PAB) utilized in infants and young children with LV-DCM and preserved RV function are able to improve LV function via VVI; it is hypothesized, that functional recovery can be achieved in almost 80% especially of infants with LV-DCM despite criteria for listing to orthotopic HTx. The review summarizes details of the current perioperative treatment enabling each pediatric heart center to utilize rPAB as a strategy for functional recovery, even in centers without the option for Htx. Of course, future studies are needed to delineate the geometrical, temporal and molecular mechanisms of PA-banding-induced ventricular crosstalk and to examine their potential modulation through mechanical, electrophysiological and pharmacological interventions, but our patients are born, now.

Keywords: Dilative cardiomyopathy; children; congestive heart failure (CHF); pulmonary banding; recovery.

Figure 1

Summarizes the pulmonary artery banding (PAB) effects on the right (RV) and left ventricle (LV). (A) Depicts the magnet resonance imaging (MRI) in four-chamber view of an infant with left ventricular dilated cardiomyopathy (LV-DCM); (B) shows functional regeneration of the LV based on the PAB induced ventriculo-ventricular interaction (VVI); the MRI was performed before the PAB induced RV hypertension was unloaded by transcatheter balloon dilation. IVS, interventricular septum; LA, left atrium; MV, mitral valve; TV, tricuspid valve.

Figure 2

Shows the open chest and pericardial approach for performing pulmonary artery banding (PAB); the PAB is already placed, the 21 gauge (arterial) cannula is still in place measuring the RV pressure before and after PAB placement.

Figure 3

Distinctive perioperative treatment.