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J Thorac Cardiovasc Surg 2006;131:928-929
© 2006 The American Association for Thoracic Surgery

Letter to the Editor

FloWatch and pseudoaneurysm: Complication versus coincidence

Antonio F. Corno, MD, FRCS, FACC, FETCS a , Marco Pozzi, MD, FRCS, FETCS a , Ludwig K. von Segesser, MD, FACS, FETCS b

a Liverpool, United Kingdom
b Lausanne, Switzerland

To the Editor:

Michel-Behnke and colleagues 1 Go reported the development of pseudoaneurysm of the main pulmonary artery after implantation of an adjustable FloWatch-PAB for pulmonary artery banding.

The observed complication has been reported as subsequent to the device implantation, but no data were available to consider it as consequent to the use of the device itself. The authors carefully specified that "the mechanism of rupture of the pulmonary artery with pseudoaneurysm formation is unclear but might have been due to a lesion set during preparation." 1 Go Their conclusion was that "careful preparation of the pulmonary trunk and smooth placement of the device around it seem essential to prevent aneurysm formation." 1 Go

Pseudoaneurysm formation is a well-known complication of conventional pulmonary artery banding. 2 Go Although we appreciate the suggestions proposed by Michel-Behnke and colleagues, 1 Go and we could not agree more on the importance of a very careful dissection of the pulmonary artery to avoid a "via falsa" for the placement of the band, we respectfully disagree with the observation that the FloWatch-PAB could be implicated with the mechanism of pseudoaneurysm formation.

Looking carefully at the available intraoperative images, the main pulmonary artery appears with a visible mark like a previous conventional banding. If this was the case, the surgical dissection of the adhesions from the previous operation could have contributed to the observed complication, independently from the use of FloWatch-PAB. Also, the time frame of the formation of the pseudoaneurysm (7 days) is quite unusual for such a complication.

Furthermore, among the several advantages of the FloWatch-PAB, 3,4 Go 3 in particular are useful to reduce the incidence of pseudoaneurysm formation in comparison with the conventional banding. First is the capability of performing a progressive narrowing of the pulmonary artery with a gradual increase of the pressure gradient through the banding, avoiding the traumatism of the sudden constriction of a dilated, hypertensive, fragile pulmonary artery. 3,4 Go Second is the shape of the device (banana-like), allowing a reduction of the cross-sectional area of the pulmonary artery without modification of the length of the circumference of the pulmonary artery itself. This is a major advantage on conventional banding, in which reduction of the cross-sectional area was obtained with significant circumferential reduction of the length of the pulmonary arterial wall. 5 Go Because of the shape of the device, there is not need for additional sutures to fix the device to the wall of the pulmonary artery to prevent migration, as for the conventional banding. Finally, because of the 2 above advantages, we were able to show in our animal experiments normal macroscopic and histologic aspects of the pulmonary artery in correspondence of the placement of the device up to 14 months with the device in situ. 3 Go

The experimental data have been confirmed in the clinical experience, extended to 26 patients in the combined series of Lausanne and Liverpool, and extended to a total number of 67 devices implanted to our knowledge, with the only pseudoaneurysm in the case reported by Michel-Behnke and colleagues. 1 Go

Furthermore, the absence of lesions of the wall of the pulmonary artery has been substantiated by the observation that, as previously observed in all animals at the moment of FloWatch-PAB removal 3 Go and in all 12 in the combined series of Lausanne and Liverpool who underwent FloWatch-PAB removal at the time of intracardiac repair, there was no need for pulmonary artery reconstruction because the pulmonary artery expanded to the normal size with the simple FloWatch-PAB removal. 5 Go


   References
Top
 References
 

  1. Michel-Behnke I, Akintuerk H, Valeske K, Thul J, Mueller M, Schranz D. Pseudoaneurysm of the pulmonary trunk after placement of an adjustable pulmonary artery banding device (FloWatch-PAB) in a patient with muscular ventricular septal defect. J Thorac Cardiovasc Surg 2005;130:894-895.[Free Full Text]
  2. Cordell AR. Complications of pulmonary artery debanding. In: Cordell AR, Ellison RG, editors. Complications of intrathoracic surgery. Boston: Little, Brown and Company; 1979. pp. 162-166.
  3. 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]
  4. Corno AF, Bonnet D, Sekarski N, Sidi D, Vouhé 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]
  5. Corno AF, Prosi M, Fridez P, Zunino P, Quarteroni A, von Segesser LK. No more pulmonary artery reconstruction after banding. Computational fluid dynamics and clinical evidence. Eur J Cardiothorac Surg. 2006;29:93-96.[Abstract/Free Full Text]



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Home page
 J. Thorac. Cardiovasc. Surg.Home page
A. F. Corno, E. J. Ladusans, M. Pozzi, and S. Kerr
FloWatch versus conventional pulmonary artery banding.
J. Thorac. Cardiovasc. Surg., December 1, 2007; 134(6): 1413 - 1420.
[Abstract] [Full Text] [PDF]

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