World Journal of Medical and

Surgical Case Reports

Case Report

Open Access

Adjustable Pulmonary Artery Banding: A new strategy

now available in Asia

Ahmad Mahir Shamsuddin1, MD, Mohd Rizal Mohd Zain2, MMed, Ahmad Mohd
Nikman3, MMed, Antonio F. Corno1,2, FRCS
1
Pediatric and Congenital Cardiac Surgery Unit, Department of Surgery; 2Department of
Pediatrics; 3Department of Anesthesia, School of Medical Sciences, Health Campus, Universiti
Sains Malaysia Kubang Kerian, Kelantan, Malaysia
This is an Open Access article distributed under the terms of the Creative Commons Attribution License
(http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium,
provided the original work is properly cited.

Abstract

The strategy of using the telemetrically adjustable pulmonary artery banding FloWatch-PAB
was introduced in Asia in an infant with multiple ventricular septal defects. A child 3 months old,
4.4 kg, after 2 months of hospitalization because of repeated chest infections due to the
presence of multiple ventricular septal defects, atrial septal defect, patent ductus arteriosus and
pulmonary hypertension, underwent successful palliative surgery with closure of patent ductus
arteriosus and pulmonary artery banding with FloWatch-PAB. This new strategy available now
in Asia can offer a new possibility of treatment of complex congenital heart defects with lower
mortality and morbidity.
Keywords adjustable pulmonary artery banding, congenital heart disease, multiple ventricular
septal defects, palliation, pulmonary artery banding
Introduction
days, in respiratory distress and heart failure.
Chest X-ray (Figure 2) showed cardiomegaly
The telemetrically adjustable pulmonary
(cardio-thoracic ratio 72%) and evidence of
artery
banding
(PAB)
FloWatch-PAB
pneumonia. The diagnosis of RSV pneumonia
(Leman Medical Technologies, Lausanne,
was confirmed, and he remained in hospital
Switzerland) was introduced in Asia for
with oxygen dependency despite anti-failure
multiple ventricular septal defects (VSDs).
treatment (frusemide, spironolactone and
enalapril).
Case Report
Single stage repair of the multiple VSDs was
A 2 month-old child with multiple VSDs (a
judged having too high risk because the
large perimembranous and two muscular
clinical condition of the patient, and therefore
defects) and patent ductus arteriosus (PDA)
a palliative approach with closure of PDA and
(Figure 1), was admitted at the age of 2
PAB with the adjustable FloWatch-PAB was
months, weight 4.2kg, after having fever for 2
decided.
Address for correspondence and reprint requests to:
Ahmad Mahir Shamsuddin, MD, Pediatric and Congenital
Cardiac Surgery Unit, Department of Surgery, School of
Medical Sciences, Health Campus Universiti Sains Malaysia
16150 Kubang Kerian, Kelantan, Malaysia Email amahir@gmail.com
2014 Shamsuddin A et al. Licensee Narain Publishers Pvt.
Ltd. (NPPL)
Submitted: Friday, May 16, 2014; Accepted: Sunday, June 01,
2014; Published: Friday, June 20, 2014

36

At 3 months of age, 4.4 kg, the patient

underwent
surgery.
Through
median
sternotomy the PDA was closed with single
metal clip and a FloWatch-PAB was
implanted (Figure 3), with increase of the
systemic pressure from 57/30 mean 38mmHg
to 76/39 mean 51mmHg. During the

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World J Med Surg Case Rep 2014;3:36-39

Figure 1 Pre-operative echocardiography

showing multiple ventricular septal defects: a
large peri-membranous defect and two
muscular defects.

Adjustable Pulmonary Artery Banding

saturation of 97% on room air. The patient

was discharged on 29th post-operative day
with diuretics and vasodilators. Three months
after surgery he is doing well, and the weight
increased to 5.6 kg, with percutaneous
oxygen saturation of 98% on room air. Last
echocardiography showed the complete
closure of the two muscular VSDs (FIGURE
4), with peak pressure gradient across the
PAB of 62mmHg. The device tightening has
been reduced from 65% to 60%, reducing
the pressure gradient to 56mmHg.
Discussion
FloWatch-PAB
is
an
implantable,
telemetrically controlled device, with the
variations in the cross-sectional area achieved
by a piston driven by an electric microengine. The adjustments are obtained with an
external control unit delivering by electromagnetic coupling the energy and commands
to drive the micro-engine.

Figure 2. Chest X-ray after admission, showing

cardiomegaly and presence of pneumonia.

procedure the percutaneous oxygenation

saturation remained around 93% with
FiO2=0.5. Echocardiography showed a peak
pressure gradient of 27mmHg after tightening
the FloWatch-PAB from 5% to 30%.
The initial post-operative period was
complicated by repeated episodes of failed
tracheal extubation, without evidence of
airways infection, as confirmed but all
negative cultures. Eventually after two weeks,
the patient was successfully extubated.
Progressive adjustments of the FloWatchPAB tightening were done throughout the
hospitalization, with last one on postoperative day 27th, to reach 65% of
tightening. Echocardiography showed a peak
pressure gradient across the PAB of 52mmHg
with non-invasive systemic blood pressure of
100mmHg
and
percutaneous
oxygen
37

The device, after long-term experimental

studies [1], has been successfully applied for
various congenital heart defects in different
institutions, with substantial reduction of
mortality and morbidity in comparison with
the conventional PAB [2-6].
The reasons behind the proven clinical
advantages of the FloWatch-PAB are the
progressive tightening of the pulmonary
artery over time, with easy adaptation of
heart and lungs to the changes in pressures
and flows, providing lower early mortality and
morbidity, reduced ICU and hospital stay in
comparison with the conventional banding
[3]. In the follow-up repeated both tightening
and reopening of the device with the remote
control, with the patient awake and not under
general anesthesia, for as long as 8 years
period were reported [3-5,7]. The possibility
of successfully releasing the PAB years after
implant has never been achieved in any of the
adjustable PAB reported in the literature. This
is a very important advantage when
considering infants with multiple VSDs, where
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World J Med Surg Case Rep 2014;3:36-39

Figure 3. Intra-operative photograph showing

the device at the moment of implantation (A)
and after the box was moved to the left side
before chest closure (B).

it is possible to release the FloWatch-PAB

endless times when the patient comes for the
clinic follow-up with decreasing percutaneous
oxygen saturation because of intra-cardiac
bidirectional shunt due to the overgrowth. A
simple
telemetric
FloWatch-PAB
adjustment allows to reduce the tightening of
the PAB and give to the patient additional
time to grow in view of the second stage
repair. This allowed to perform the complete
repair at the wanted age and body weight,
with the patients in good conditions.
In addition, no plasty reconstruction of the
main pulmonary artery is required at the
moment of device explanation for intracardiac repair [4].
In patient with multiple VSDs the
conventional PAB as well as the one-stage
repair were always reported with elevated
early and late mortality; substantial morbidity
with residual defects, ventricular arrhythmias
and biventricular dysfunction was also
reported in an elevated percentage of
patients after first-stage repair [5]. Our new
strategy of two-stage approach, with
palliation by FloWatch-PAB followed by later
repair,
provided
good
results
[5].
Spontaneous closure of the muscular VSDs
occurred over time, leaving the possibility of
closing the remaining VSD at older age and
higher body weight, or simply late removal of

38

Shamsuddin AM et al.

Figure 4. Post-operative echocardiography 3

months after device implantation, showing
complete closure of the two muscular septal
defects.

the device in patients with multiple muscular

VSDs [5].
The same strategy was successfully applied in
our infant, allowing him to recover from a
very precarious clinical condition, and to grow
and wait for the complete repair, facilitated
by the only need to remove the device and
close the peri-membranous VSD in much
better condition.
The FloWatch-PAB, used in several other
congenital heart defects as palliation for biventricular and for uni-ventricular hearts [25,7] and for left ventricular re-training [3,8],
so far has been implanted in 9 European
countries (Belgium, Denmak, England,
France, Germany, Greece, Italy, Switzerland,
Sweeden) and in Saudi Arabia. This is the first
implantation in Asia, and the availability of
the device in the region can offer a new
possibility of treatment of complex congenital
heart defects with lower mortality and
morbidity.
Conclusion
The advantages of FloWatch-PAB has been
shown markedly reduced the mortality and
morbidity of patients required for treatment
and its availability in Asia has provides new
possibilities of management in complex
congenital heart defects.
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World J Med Surg Case Rep 2014;3:36-39

Conflicts of Interests Statement

The authors declare that there are no
conflicts of interests
Authors contributions
AMS: carried out the literature search and
prepared the draft manuscript,
MDMZ: carried out the experiments and
interpreted the results, designed the study
and performed the analysis
AMN: carried out the experiments and
interpreted the results, designed the study
and performed the analysis
AFC: conceived the study, participated in
design and edited the final manuscript.
All authors read and approved the final
manuscript for submission
Ethical Considerations
The written informed consent was obtained
from patient for publication of this case
report.
Acknowledgement
None
Funding
This case report has received no specific
funding.
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