Pulmonary Artery Banding
Because most neonates undergo total correction for congenital heart defects, banding of the pulmonary artery is only indicated for specific subgroups of patients. These include patients with multiple muscular ventriculoseptal defects or ventriculoseptal defects complicated by other noncardiac congenital anomalies. Patients who present after 4 to 6 weeks of age with simple transposition of the great arteries may require preliminary pulmonary artery banding to prepare the left ventricle for an arterial switch procedure (see Chapter 25). Banding of the pulmonary artery is also performed in some patients with univentricular hearts and pulmonary overcirculation (see Chapter 30).
INCISION
Most surgeons use a median sternotomy because it allows the anatomy to be evaluated more accurately. A left thoracotomy incision is used in some patients, especially if the banding is performed in conjunction with the repair of a coarctation.
TECHNIQUE
Through a median sternotomy, the pericardium is opened longitudinally after resecting the thymus. (Removing the entire thymus in this surgery makes dissection at reoperation easier.) A patent ductus arteriosus, if present, is first ligated (see Chapter 14). The main pulmonary artery is dissected free from the aorta and the origin of the right pulmonary artery is identified. A band of Silastic 3- to 4-mm wide is placed around the proximal pulmonary artery and tightened until the pressure distal to the band is approximately one-third systemic with an arterial oxygen saturation no less than 75% on 50% inspired oxygen (Fig. 16.1). The constriction site on the band is made permanent with stainless steel clips or interrupted sutures. The band is then secured to the adventitia of the pulmonary artery at various intervals with interrupted 6-0 or 5-0 Prolene sutures (Fig. 16.1, inset).
Through a left thoracotomy, the pericardium is incised anterior and parallel to the phrenic nerve. The main pulmonary artery is isolated, and the Silastic band is passed around it and narrowed as described previously.
Damage from the BandThe pulmonary artery may be tense and its wall thin and friable. Regular suture material or a narrow band may cut through and produce hemorrhage that is difficult to control. 
Difficulty Passing the Band around the Pulmonary ArteryIt may be easier and safer to initially pass the tape around both the aorta and pulmonary artery through the transverse sinus and then between the aorta and pulmonary artery. 
Troublesome BleedingSmall adventitial vessels on the aorta and pulmonary artery may give rise to troublesome bleeding; they must be identified and cauterized. 
Excessive BandingThe degree of banding must not be too constrictive because this will result in unacceptable cyanosis and possible hemodynamic collapse. 
Inadequate BandingMany times, the tightness of the band is limited by the hemodynamic response of the patient. Patients with subaortic narrowing may not tolerate adequate constriction of the band. To limit the pulmonary blood flow in these patients, ligation of the pulmonary artery or a Damus-Kaye-Stansel anastomosis and shunt procedure may be required (see Chapter 30). 
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