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J Thorac Cardiovasc Surg 2005;130:894-895
© 2005 The American Association for Thoracic Surgery

Brief Communication

Pseudoaneurysm of the pulmonary trunk after placement of an adjustable pulmonary artery banding device (FloWatch-PAB) in a patient with muscular ventricular septal defect

^a Pediatric Heart Center, Justus-Liebig University Giessen, Giessen, Germany
^b Department of Anaesthesiology, Justus-Liebig University Giessen, Giessen, Germany

Received for publication February 14, 2005; revisions received March 1, 2005; accepted for publication March 15, 2005.

^_* Address for reprints: Ina Michel-Behnke, MD, Justus-Liebig University, Pediatric Heart Center, Department of Pediatric Cardiology, Feulgenstrasse 12, 35392 Giessen, Germany (Email: ina.michel-behnke{at}paediat.med.uni-giessen.de).

Single or multiple muscular ventricular septal defects (VSDs) with a significant left-to-right shunt require pulmonary artery banding (PAB) in the first months of life. An optimized flow restriction can rarely be achieved or maintained over time. Conventional PAB carries the risk of pulmonary branch stenosis and damage to the vessel wall. In 2003, Corno and colleagues ¹ reported their first clinical experience of a completely externally adjustable banding device (FloWatch-PAB) to overcome these disadvantages. Recently, the results of a multicenter study were published, in which the device was judged to be safe and effective. ² We report on a patient presenting with a huge pseudoaneurysm of the pulmonary trunk after insertion of the FloWatch-PAB device.

Methods and Results

A 3-month-old boy with a body weight of 4.2 kg had heart failure caused by excessive pulmonary shunting through a 7-mm muscular VSD and secondary pulmonary hypertension. A FloWatch-PAB device was inserted through a median sternotomy around the pulmonary artery trunk (Figure 1). The operation was uneventful, and immediately after the operation, the constriction of the banding was adjusted telemetrically to 50%. The induced restriction of the pulmonary artery flow decreased the pulmonary artery pressure to 50% of the systemic arterial pressure, with a Doppler gradient of 66 mm Hg in the pulmonary trunk.

View larger version (58K): [in this window] [in a new window]   Figure 1. Placement of the FloWatch-PAB device around the pulmonary artery trunk.

The patient continued to have excessive lung perfusion. Seven weeks after placement of the banding device, he presented with severe congestive heart failure and dyspnea. A chest x-ray film revealed a huge aneurysm of the pulmonary artery trunk (Figure 2). He was sent for surgical intervention, during which the diagnosis of a pseudoaneurysm was confirmed. The banding device was found within the pulmonary artery trunk surrounded by a capsule preventing hemorrhage up to that time. The pseudoaneurysm was resected, and the device was removed. The tricuspid valve had to be incised to expose the VSD; thereafter, the defect could be closed through insertion of a patch, which was uneventful.

View larger version (172K): [in this window] [in a new window]   Figure 2. Chest x-ray film demonstrating a pseudoaneurysm of the pulmonary artery trunk (white arrow) 7 weeks after placement of a FloWatch-PAB device (black arrow).

In the past, efforts have been made to control pulmonary flow and pressure by using banding devices that were adjusted invasively. ^3,4 Fibrosis and even necrosis of the pulmonary artery were observed. When Corno and colleagues ¹ reported their first clinical experience with a completely externally adjustable banding device (FloWatch-PAB), developed by EndoArt SA (Lausanne, Switzerland), it seemed that a dream had come true. The mechanism of controlling the width of the banding was realized through transmission of energy from an external control unit by means of radiofrequency waves. With this device, damage to the vessel wall of the pulmonary artery was not observed. ⁵ In the patient presented here, the mechanism of rupture of the pulmonary artery with pseudoaneurysm formation is unclear but might have been due to a lesion set during preparation while the FloWatch-PAB was placed. The capsule that was visualized during removal of the device prevented bleeding. Retrospectively, the rupture of the pulmonary artery should have occurred 7 days after the first operation, when pericardial effusion was diagnosed. This also explains why the banding effect was lost, and continued left-to-right shunting worsened the patient's clinical condition.

We share the same good experience as Bonnet and associates ² in 2 other patients in whom the banding worked perfectly, but nevertheless, this severe complication might occur and should be kept in mind regardless of the advantages the FloWatch-PAB offers. Careful preparation of the pulmonary trunk and smooth placement of the device around it seem essential to prevent aneurysm formation.

References

1. Corno AF, Bonnet D, Sekarski N, Sidi D, Vouhe P, Von Segesser LK. Remote control of pulmonary blood flow. initial clinical experience. J Thorac Cardiovasc Surg 2003;126:1775-1780.[Abstract/Free Full Text]
   
2. Bonnet D, Corno AF, Sidi D, Sekarski N, Beghetti M, Schulze-Neick I, et al. Early clinical results of the telemetric adjustable pulmonary artery banding FloWatch-PAB. Circulation 2004;110(suppl II):II158-II163.[Medline]
   
3. Leeuwenburgh BP, Schoof PH, Steendijk P, Baan J, Mooi WJ, Helbing WA. Chronic and adjustable pulmonary artery banding. J Thorac Cardiovasc Surg 2003;125:231-237.[Abstract/Free Full Text]
   
4. Muraoka R, Yokota M, Aoshima M, Nomoto S, Kyoku I, Kobayashi A, et al. Extrathoracically adjustable pulmonary artery banding. J Thorac Cardiovasc Surg 1983;86:582-586.[Abstract]
   
5. Corno AF, Sekarski N, Bernath MA, Payot M, Tozzi P, Von Segesser LK. Pulmonary artery banding. long-term telemetric adjustment. Eur J Cardiothorac Surg 2003;23:317-322.[Abstract/Free Full Text]
   

This article has been cited by other articles:

				A. F. Corno, M. Pozzi, and L. K. von Segesser FloWatch and pseudoaneurysm: Complication versus coincidence J. Thorac. Cardiovasc. Surg., April 1, 2006; 131(4): 928 - 929. [Full Text] [PDF]

				I. Michel-Behnke, H. Akintuerk, and D. Schranz Reply to the Editor J. Thorac. Cardiovasc. Surg., April 1, 2006; 131(4): 929 - 929. [Full Text] [PDF]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Citation Map Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Klaus Valeske Matthias Mueller Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Michel-Behnke, I. Articles by Schranz, D. Search for Related Content PubMed PubMed Citation Articles by Michel-Behnke, I. Articles by Schranz, D.