Gotsman, M.S.

le Roux, B.T.

van der Horst, R.L.

Winship, W.S.

English

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27 September 1969 S.A. TYD KRIF VIR GE EESKUNDE 11992 had a moderately raised systemic venous renin and ef-fluent plasma renin in the right kidney (Table Il). Bothcases have shown a very good postoperative drop inblood pre sure which has been maintained for the last4 months.We feel that the biological method used in this tudyfor the assessment of renin is reliable, but requires atrained staff and adequate laboratory facilities. Thisestimation should not be a routine, investigatorytool, but it should be done where routine studies to diag-nose renovascular hypertension are inconclusive. As canbe seen from the 3 patients studied, there is a significantincrease in renin in the effluent blood of the ischaemickidney. This is unfortunately not a constant finding inca es of renovascular hypertension. If it is decided toobtain pre-operative renin samples, they should be takenfrom both renal veins, possibly applying the method asdescribed by Mickelakis et al." The reason for this dif-ferential sampling of the renal veins is that the systemicrenin values can often be misleading (falsely low values),and this method of sampling helps to delineate thei chaemic kidney.SUM lARYThree cases of renovascular hyperten ion are di cu sed in thispaper. Renin estimations were done on each case before andduring surgery. The method of renin e timation used in thesecases is discussed, and it is suggested that to adequately assessrenovascular hypertension, blood should be differentiallysampled from each renal vein.REFERE CES1. Braun-Menendez. E.. Fasciolo. 1. C.. Lelair. L. F.. Munoz. J. M. amITaquini. A. C. (1946): ReIlat Hypertellsioll. Springfield. Ill.: Charie-e. Thomas.2. Goldblall. H. (1937): Ann. Intern. Med.. \1. 69.3. Tclem (1964): Bull. N. Y. Acad. Med.. 40. 745.4. Blacquier, P., Bohr. D. F. and Hoobler. S. W. (1960): Amer JPhysiol.. \98, lt48.5. Peart. W. S.. Robertson. J. 1. S. and Grahame·Smith. D. G. ()9~1\:Circulat. Res .. 9. 1171.6. Langford. H. G. (1963): Perspect. Bioi. Med .. 6. 372.7. Bamer. F. C.. Casper. A. G. T.. Delea. e. S. and Slater. J D H(1961): Metabolism. \0. 1006.8. Davies, J. O. (1962): Physiologist. 5. 65.9. Brown. J. J., Davies, D. L., Lever. A. F. and Roberlson. J. I. S(963): Lancet, 2, 278.10. Helmer. O. M. and Judson. W. E. (1963): Circulation. 27. 1050.11. Gunnells, J. C. and Grim. C. E. (1967): Arch. Intern. Med., 119. 232.\2. Mickelakis. A. M., Foster. J. H.. Liddle. G. W.. Rhamy. R. 1-.:.Kuchel, O. and Gordon, R. D. (1967): Ibid .. 120. 444.BANDING OF THE PULMONARY ARTERY*R. L. VA DER HORST, M.B.. CH.B., M.MED. (PAED.) (CAPE TOWN); W. S. WI SHII', M.B.. CH.B., M.MED.(PAED.) (CAPE TOWN); B. T. LE Roux, CH.M. (CAPE Tow), F.R.C.S. (EDIN.); AND M. S. GOTSMA' , M.D. (CAPE TOWN).M.R.C.P., M.R.C.P. (GLASG.), D.T.M. & H. (L'POOL); Cardia-Thoracic Unit, Wentworth Hospital and Universityof Natal, DurbanInfants with a ventricular septal defect and a large left-to-right shunt may develop progressive cardiac failurewhich does not respond to medical treatment. In seriouslyill infants under the age of I year, corrective surgery hasa high mortality: as management, preliminary banding ofthe pulmonary artery is preferred to improve the clinicalstatus. The band obstructs egress of blood from the rightventricle, diminishes the left-to-right shunt and pulmonaryblood flow and reduce the distal pulmonary artery pres-sure, thereby protecting the muscular pulmonary arteries*D:lte received: 21 February 1969.from the development of progressive intimal changes."The purpose of this paper is to report clinical ex-perience with pulmonary artery banding in 7 patients andserial haemodynamic studie before and immediatelyafter surgery.CASES AND METHODSThe clinical profiles of the patients are shown in Table r.The ages of 6 of the patients at the time of initial studyranged from 2 to 15 months; one patient of 3 years hadmultiple defects of the ventricular septum and was con-sidered to be unsuitable for definitive repair.TABLE I. SUMMARY OF CLI lCAL FINDINGSAge aT Age aT WeighT aT Age at Weighl atonset of first first Age at postop. postop.Patient Sex Race symptoms Symptoms study study surgery study study DiagnosisD.G. F C Infancy Heart failure, 81' months 8 lb. 10 oz. 81' months 2 weeks 8 lb. 10 oz. VSDfailure to laterthriveC.S. F C 4 months Heart failure 5 months 1I lb. 51' months 3 year 52 lb. ECDS.N. M B lnfancy Repeated resp. 3 years 29 lb. 3 years 4 year 31 lb. Multipleinfections, mu cularheart failure VSDS.D. M C Infancy Repeated resp. 2 months 7 lb. 10 oz. 51' month 10 months lb. VSDinfections,heart failureB.W. F W Infancy Heart failure, 31' months 61b. 6!- month 9 months 13 lb. V 0resp. infections,failure tothriveH.R. F W Infancy Heart failure 15 months 161b. 16 months 39 months 27 lb. VSDV.L. M Infancy Heart failure 6 months 10 lb. 6 07. 6 monthC = Coloured; B = Bantu; W = White; I = Indian.1200 S.A. MEDICAL JOUR AL 27 September 1969TABLE 11. HAEMODY AMIC DATARight Pulmonaryventricular artery Aorticpressure pressure pressurePatient Age (mm.Hg) (mm.Hg) (mm.Hg)D.G. Pre-op. 8-\- months 100/2 100/50 100/60POSlOp. 8~ months 90/3 45/28 90/37C.S. Pre-op. 5 months 5/3 75/15 75/45POSlOp. 3 years 90/10 50/20 90/60S. I Pre-op. 3 years 75/50 75/25 75/50POSlOp. 4 years 85/5 30/10 95/655.0. Pre-op. 2 months 88/3 82/40 100/63Postop. 10 months 65/5 20/10 65/40H.W. Pre-op. 3-\- months 88/2 88/12 88/45POSlOp. 8~ months 87/0 12·5/7'5 87/50H.R. Pre-op. 15 months 60/10 60/40 100/75Postop. 39 months 60/3 30/15 125/75V.L. Pre-op. 6 months 90/6 85/50 90/70Pulmonarybloodjlow(litre/min./sq. m.)8·03·85·54·3154·57·25·58·23·58·54·85·9Systemicbloodjlow(litre/mill./sq. m.)3·04·11·72·42·852·12·72·92·23·52·33·32·2PBF%SBF 02·70·923·22·055·32·12·71·93·71·03·71·452·7PulmonaryI'ascularresistance(units/ 'sq. m.)6·57·87·30·852·72·85·51·84·70·64·43·711·0Systemicvascularresistance(units/sq. m.)28·015·029·027·017· 532·026·010·0292038·030·034PVR%SVR 0235225315921I163121232RESULTSPostoperative haemodynamic and cine-angiocardiographicstudies were undertaken I - 10 months after surgery tomeasure the objective results of surgery.Five patients had isolated ventricular septal defects, I hadan associated persistent ductus arteriosus (which wasdivided and ligated at the time of pulmonary artery band-ing) and 1 had a ventricular septal defect as part of a com-plete endocardial cushion defect.The haemodynamic information is shown in Table n.Before operation the patients had a pulmonary to systemicblood flow ratio which ranged from 2·7: I to 5·2: 1.Pulmonary arterial hypertension was due mainly to theincrease in pulmonary blood flow, and the ratio of pul-monary to systemic vascular resistanceranged from 16 to 32°b. The patients'clinical state improved after operationand, although they still required digi-talis and diuretics, all began to growand the incidence of respiratory infec-tions was reduced. Heart size was notaltered. but pulmonary plethora di-minished radiographically (Fig. J).Two patients deteriorated later.Postoperative investigation wasundertaken in 6 ef the infants. Threeshowed appreciable reduction in thevolume of the left-ta-right shunt, Jhad no detectable shunt and anotherhad a small right-ta-left shunt at ven-tricular level, while in the infant witha complete endocardial cushion defectwith a bidirectional shunt the size ofthe left-ta-right shunt was reduced. Sixhad a significant gradient at the levelof the band; in these the systolicpulmonary artery was reduced and thepulmonary vascular resistance i~ nownormal (Fig. 2).Fig. l(b). 3 months after banding ofthe pulmonary artery. Heart size hasnot altered but the plethora hasimproved.Fig. 1(0). Anteroposterior view ofchest X-ray of patient D.G. beforesurgery, showing cardiomegaly, pul-monary plethora and dilated mainpulmonary artery.All the infants had failed to thrive, woce underweight,had repeated respiratory tract infections and, although inhospital, were in cardiac failure re i tant to intensive medi-cal care. Investigation--eardiac catheterization and selectivecine-angiocardiography-was undertaken only in patientswho did not respond to conservative medical treatment.The size of the left-to-right shunt and the pulmonaryvascular resistance were calculated from oxygen satura-tion determinations and measurements of pressure invarious chambers and vessels.The technique of banding of the pulmonary artery is wellestablished: At left thoracotomy i-in. nylon tape wasu ed to encircle and constrict the pulmonary artery toreduce the pressure distal to the band by about 50°0.whereupon the band was secured with transfixing sutures.27 September 1969 S.A. TVDSKRtF VIR GE EESKU'DE 1201One patient deteriorated 3 months after the post-operative study and further investigations showed thatthe gradient had disappeared; the band across the pul-monary artery probably disintegrated. The patient now hasa slightly elevated puLmonary vascular resistance.Fig. 2. Lateral view of right ventriculogram showing effec-tive banding of the pulmonary artery (arrow).The patient with a complete endocardial cushion defectdied in chronic heart failure 2t years after banding. Atautopsy there was no evidence of constriction of the pul-monary artery. Presumably the band had disintegrated.The other 5 patients maintained their improvement andare all thriving and out of hospital.DISCUSSIO'The natural history of ventricular septal defects may bemodified by several factors: Functional reduction in thesize of the defect, often with complete closure;' pro-gressive pulmonary vascular changes;"- progressive obstruc-tion to the outflow tract of the right ventricle;' and inter-current chest infection and cardiac failure which may leadto death. In the majority of patients symptoms improve asthe children grow older. However, there is a small groupof patients in whom the large left-to-right shunt leads torepeated respiratory tract infections and cardiac failurewhich require inpatient hospital care and treatment. Pul-monary artery banding is indicated in these infants and isoften life-saving. Where facilities are available, these in-fants with heart failure are best treated for long periods inhospital with intensive medical treatment and the use ofdigoxin, diuretics and low-salt diet.Frequent upper and lower respiratory tract infectionsmay precipitate admission to hospital or may prolong stayin hospital. Careful follow-up is then needed. Most of ourpatients live in remote areas far from the major hospitals.Return visits for follow-up are irregular; drug therapy isoften stopped or the incorrect dose is given and the infantsfare poorly. In our environment, ther;fore, patients with alarge left-to-right shunt and significant pulmonary hyper-tension are admitted to hospital if they develop heartfailure or respiratory infections. Investigation is undertakenif they do not respond to medical treatment. and bandingof the pulmonary artery i undertaken as 'a preliminaryoperation.The results in this selected group of patients have beenrewarding and are in keeping with other report in theliterature."""" There has been no operati e mortality andall the patients showed symptomatic improvement; 5 arenow very well and the pulmonary arteries are protectedfrom a high pressure and torrential blood flow. The banddisintegrated in 2 patients: one developed evere heartfailure and the other one died.It is unlikely that a palliative operation will increa e therisk of subsequent corrective surgery. Two problems willbe encountered: the pericardium may have been openedso that adhesions may be present. If the banded pulmonaryartery segment is very small, an inlay gu et will be neededto enlarge the vessel.Ideally we would like to undertake corrective surgeryin the very small infant; improvement in open hearttechniques will make this feasible, but until then band-ing of the pulmonary artery will improve these critically illinfants.SUM 1ARYPulmonary artery banding was undertaken in 7 small children:5 had simple ventricular septal defect with refractory cardiacfailure, I had multiple defects of the ventricular septum andI had complete endocardial cushion defect. All had a largepulmonary blood flow and similar systolic pressures in thetwo ventricles.The children improved after surgery, and postoperativecardiac catheterization and cine-angiocardiography confirmedthat the distal pulmonary artery pressure and flow had beenreduced significantly. Late disintegration of the band occurredin 2 patients: heart failure returned in both and I died 2·tyears later.Pulmonary artery banding is a satisfactory preliminary opera-tion in these very ill children.We wish to thank Dr S. Disler, Medical Superintendent ofWentworth Hospital, for permission to publish, and the EthicalDrug Association Foundation for financial assistance.REFERE 'CESI. Muller, W. H. inr and Dammann, J. F. inr (1952): Surg. Gynec.Obstet.. 95. 213.2. Goldblatt. A., Bernhard. W. F., Nadas, A. S. and Gro... R. W(1965): Circulation, 32, In.3. Dammann. J. F. inr, McEachen. J. A .. Thompson. W. M. jnr.Smith. R. and Muller, W. H. inr (1961): J. Thorac. Cardiovasc. Surg .42, 722.4. Takahashi. M .. Lurie, P. R .. Petry. E. L. and King. H. (1968): AmerJ. Cardiol., 21, 174.5. Aguslsson, M. H., Arcilla. R. A.. Bicolf. J. P.. Moncada. R. anJGasul. B. M. (1963): Pediatrics, 31. 95 .6. Dammann. J. F. jnr and Ferencz. C. (1956): Amer. Heart J .. 52. 2107. Heath, D .. Helmholz. H. F. inr. Burchell. H. B.. Du Shane. J. Wand Edwards. J. E. (195): Circulation. 18. 1155.8. Arcilla. R. A.. Aguslswn, M. H .. Bicolf. J. P .. Lynfield. J .. \Vem-berg, M .. Fell, E. H. and Gasul. B. M. (1963): [bid .. 28. 560.9. Grainger, R. G .. Nagle. R. E.. Pawidapha. C.. Roberlson. D. S.Taylor. D. G .. ThornlOn. J. A., Verel. D. and Zachary. R. B. (1967):Brit. Heart 1.. 29, 289.10. Dammann. J. F. jnr and Carpenter, M. A. ill \Valson. H .. ed. (196 ):Paediatric Cardiology. chapt. 31. London: L1oyd·Luke (Medical Books)11. Vince. D. J. (1967): Canad. Med. Assoc. J .. 97. I.12. \Villman. V. L.. Cooper, T .. Mudd, J. G. and Hanlon, C. R (1962):Arch. Surg .. 85. 745.

Banding of the pulmonary artery

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Banding of the pulmonary artery

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