Pulmonary Artery Banding Cost in India

“The cost of Pulmonary Artery Banding starts from USD 2,500 in India. The Pulmonary Artery Banding hospitals in India promise unparalleled health treatments at low-cost packages.

Pulmonary artery banding (PAB) is a palliative surgical technique used by congenital heart surgeons to stage the operative correction of congenital heart defects.
This technique was previously widely used as an initial surgical intervention for infants born with cardiac defects that included left-to-right shunting and pulmonary over-circulation.
PA banding is therefore used to limit PBF (Pulmonary blood flow) in infants who are anatomically or physiologically uncorrectable at this time and have an excessive PBF from their native PA.
The majority of patients requiring PA banding have complex anatomy. Patients with double-outlet RV with hypoplastic LV, as well as those with unbalanced AVSD and hypoplastic LV, may require PA banding.
These patients are generally in heart failure, with low systemic perfusion and high PBF. To reduce flow, the surgeon places a restrictive band across the main pulmonary artery.
Band placement is extremely imprecise and requires careful assistance from the anesthesia team to be completed successfully.
Over the last two decades, early definitive intracardiac repair has largely replaced palliation with PAB.
Although the use of PAB has recently decreased significantly, it still plays a therapeutic role in some subsets of patients with congenital heart disease.
It is important to note that the exact approach and details of pulmonary artery banding may differ depending on the patient’s condition and the surgical team’s preferences.
Pediatric cardiologists and cardiac surgeons collaborate to develop each patient’s most effective treatment plan.

The Goal of PA Banding in India

The primary goal of PAB is to reduce excessive pulmonary blood flow while protecting the pulmonary vasculature from hypertrophy and irreversible (fixed) pulmonary hypertension.

It aims to balance circulation by restricting blood flow to the lungs, allowing more oxygenated blood to be pumped throughout the body.

It regulates blood flow between the systemic circulation (the body) and the pulmonary circulation (the lungs).

PAB has recently been used in the preparation and “training” of the left ventricle (LV) in patients with D- TGA who are being evaluated for a delayed arterial switch procedure.

Therefore, Pulmonary artery banding is frequently viewed as a temporary solution. In some cases, it acts as a bridge to a more permanent surgical repair or correction of the underlying congenital heart defect.

Types of Pulmonary Artery Bands

The type of band used in PAB procedures varies depending on the patient’s specific needs. Some common types are:

Fixed Bands: These bands are predetermined in size and are wrapped around the pulmonary arteries. Fixed bands are commonly used in straightforward cases where a specific level of constriction is required.

Adjustable Bands: Adjustable bands enable precise control of blood flow by allowing adjustments after surgery. This flexibility is especially useful when the child is still growing and needs regular adjustments to accommodate their growing size.

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Indicators

Common indications include conditions characterized by excessive blood flow to the lungs, such as certain types of ventricular septal defects (VSD) or atrioventricular septal defects (AVSD).

Pulmonary artery banding is performed primarily with two objectives:

Reduce pulmonary blood flow in patients with significant pulmonary overcirculation due to significant left-to-right shunting as a palliative measure before definitive surgical repair.
Increase afterload to the morphological left ventricle (which functions as a low-pressure pulmonary ventricle) to prepare or “train” the ventricle to become a systemic ventricle before an arterial switch procedure in patients with transposition of the great arteries (TGA).

Clinical scenarios in which pulmonary blood flow requires limitation via PAB are:

Multiple or single VSD with confounding surgical complications (e.g., very low birth weight, sepsis, pneumonia, intracranial hemorrhage, multiorgan failure, etc.).
Palliate unbalanced AVC defects with borderline left ventricular hypoplasia before proceeding with potential biventricular repair after further development and growth.
High-risk infants with hypoplastic left heart syndrome receive bilateral PAB and patent ductus arteriosus stenting for short-term surgical palliation.
Muscular “Swiss cheese” ventricular defects (VSD) in infants, may be technically difficult to repair and/or necessitate ventriculostomy

Clinical scenarios for patients who need LV training include:

LV training is necessary for patients with D-TGA who come in late for a staged arterial switch operation, L-TGA patients for a later staged double switch procedure, L-TGA patients without VSD to reduce tricuspid regurgitation, and patients with single ventricle anatomy during bidirectional Glenn shunt placement.

As an adjunct procedure in patients with single ventricle anatomy and antegrade pulmonary blood flow during bidirectional Glenn shunt placement to maintain some antegrade flow while keeping superior vena cava pressure low.

Who is the best candidate for PA Banding?

The decision to perform pulmonary artery banding (PAB) and staged cardiac repair on patients is based on the experience and training of the pediatric cardiologists and congenital heart surgeons at each institution.
The medical team carefully evaluates each patient’s condition to determine the most appropriate course of action.
For patients with pulmonary overcirculation and left-to-right shunting, a staged approach is typically taken to reduce pulmonary blood flow (PBF) before proceeding with more definitive repair.
This approach helps to optimize the patient’s condition and reduce the risk of complications during the procedure.
In contrast, patients with transposition of the great arteries (TGA) require a staged approach to training the left ventricle (LV) before undergoing the arterial switch procedure.
This approach prepares the LV to handle the demands of the new circulatory system after the procedure and can help improve outcomes.
Overall, the decision to perform PAB and staged cardiac repair is complex and requires careful consideration of the patient’s individual needs and medical history.
The medical team works closely with patients and their families to develop a treatment plan that is safe, effective, and tailored to their specific conditions.

Contraindications

There may be symptoms or conditions that make the PAB as a course of action inadvisable:

Infants with specific single ventricle defects (e.g., double inlet left ventricle or tricuspid atresia with TGA where there is a risk of subaortic obstruction in the future) or aortic arch anomalies Pulmonary artery banding can cause ventricular/Conal hypertrophy, worsening the subaortic stenosis.
Patients with a pressure gradient across the systemic outflow tract/subaortic region greater than 15-20 mmHg may experience “double banding,” which occurs when both the systemic and pulmonary outflow tracts have significant outflow gradients, imposing a pressure overload on both ventricles.
Severe AV valve regurgitation of the pulmonary ventricle (or of the systemic AV valve in patients with single ventricle).
The increased afterload imposed by the band in this scenario may worsen AV valve regurgitation and is therefore considered a relative contraindication.
Truncus arteriosus: The short MPA in type 1 truncus arteriosus can be difficult to band and impinge on the right PA.
Furthermore, patients with Type 2 and 3 truncus arteriosus would require bilateral PAB, and balancing blood flow to both lungs is extremely difficult.
Finally, because of the continuous nature of flow in patients with truncus arteriosus, PAB placement may be less effective in limiting pulmonary flow.
As a result, for a variety of anatomical and physiological reasons, PAB is generally avoided in these patients.

Diagnosis in the case of PA Banding

In medical conditions such as ventricular septal defects (VSD) or atrioventricular septal defects (AVSD), one of the common indications is excessive blood flow to the lungs.

When a person has certain medical conditions, it can affect the structure of their heart and cause an abnormal connection between the heart’s chambers. This can lead to abnormal blood flow, which in turn can cause the lungs to become overfilled with blood.

This can result in symptoms like difficulty breathing, fatigue, and trouble exercising. If left untreated, these conditions may lead to severe complications, including heart failure and pulmonary hypertension.

Therefore, early diagnosis and treatment are crucial to managing these conditions and preventing long-term complications:

Routine laboratory tests are obtained preoperatively when a patient is being evaluated for pulmonary artery banding (PAB).
Pulse oximetry or ABG analysis should be used to determine baseline arterial oxygen saturation levels.
A baseline creatinine level should be measured and compared postoperatively during diuresis and CHF management.
Optimizing hemoglobin and hematocrit levels can improve oxygen-carrying capacity and saturation after PAB.
Echocardiography, magnetic resonance imaging with three-dimensional reconstruction, and/or cardiac catheterization are all imaging and/or diagnostic procedures.
Preoperative treatment for patients with pulmonary overcirculation and congestive heart failure (CHF) should include minimizing left-to-right shunting, improving cardiac function with inotropic support, lowering systemic afterload, and aggressive diuresis.
Mechanical ventilator support may be required to ensure adequate ventilation and oxygenation in the presence of pulmonary oedema.
Maintaining higher CO2 levels and a lower fraction of inspired oxygen (FIO2) during ventilation may help to reduce pulmonary blood flow (PBF) and oedema.
If a patent ductus arteriosus (PDA) exists, it should be reduced or closed with medical therapy (e.g., indomethacin) to reduce this source of PBF.

Cost of Pulmonary Artery Banding in India

The average PA Banding Surgery cost in India is 2500 USD.

In India, where medical expertise meets affordability, many families are considering this option for their loved ones. Pulmonary Artery Banding is a critical procedure for infants with congenital heart defects, and India provides both skilled medical professionals and affordable healthcare.

The cost of pulmonary artery banding in India can vary depending on several factors:

Hospital Facilities: The hospital’s reputation and facilities greatly impact the overall cost of surgery.
Surgeon’s Fees: Experienced cardiac surgeons may charge higher fees based on their expertise. The surgeon’s expertise and reputation are critical to a successful outcome.
Pre-and post-operative care expenses: such as medical tests, medications, and follow-up appointments, increase the overall cost.
Affordability in India: One advantage of considering Pulmonary Artery Banding in India is the relatively low cost of medical procedures. Indian healthcare facilities are known for providing high-quality care at a fraction of the cost of many other countries.

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Working on PA Banding

Congenital heart defects with left-to-right shunting and unrestricted pulmonary blood flow (PBF) caused by a decrease in pulmonary vascular resistance led to pulmonary overcirculation.
In the acute setting, this causes pulmonary oedema and congestive heart failure (CHF) in the neonate.
Within the first year of life, this unrestricted flow and pressure can cause medial hypertrophy of the pulmonary arterioles and persistent pulmonary hypertension.
Pulmonary artery banding (PAB) narrows, or stenosis, the main pulmonary artery (MPA), decreasing blood flow to the branch pulmonary arteries and lowering PBF and pulmonary artery pressure.
In patients with cardiac defects that cause left-to-right shunting, restricting PBF reduces shunt volume, which improves both systemic pressure and cardiac output.
A reduction in PBF also reduces the total blood volume returning to the LV (or systemic ventricle), which frequently improves ventricular function.

Preparing for Pulmonary Artery Banding in India

Echocardiography should be used as part of the preoperative evaluation to provide a detailed anatomic definition.
Additional imaging with magnetic resonance imaging and/or cardiac catheterization may be useful in providing a more detailed anatomical and physiological evaluation of complex defects, but these are typically not required for simple defects such as a VSD.
Pre-operative management should focus on reducing left-to-right shunt through systemic afterload reduction and aggressive diuresis, particularly in patients with congestive heart failure symptoms.
Respiratory support may be required in patients with severe pulmonary hyper circulation, and adequate oxygenation and ventilation are maintained using mechanical ventilator support, particularly in the presence of pulmonary oedema.
It is critical to avoid using too much oxygen because the pulmonary vasodilatory effect of inspired oxygen acts as a pulmonary vasodilator, increasing pulmonary flow.

Technique or Treatment

The standard surgical approaches to pulmonary artery banding are:

1) Anterior left thoracotomy through the 2nd/3rd intercostal space.
2) Left lateral thoracotomy through the 3rd/4th intercostal space.
3) Medial sternotomy.

Anterior/lateral thoracotomy exposes MPA by retracting the thymus and dissecting the pericardium anterior to the left phrenic nerve.
Cardiopulmonary bypass is recommended when median sternotomy is performed, especially in conjunction with other surgeries such as atrial septectomy.
In patients with TGA or single ventricle anatomy, median sternotomy is preferred because it provides excellent access to MPA (main pulmonary artery).

The Surgical technique

After exposure to the aorta and MPA, the band is ready for placement. Banding uses a variety of materials.
Few surgeons prefer umbilical tape because it is less likely to erode through the vessel wall and can be easily modified to be used as an adjustable band by passing it through a silastic snare.
The Trusler formula has traditionally been used to help determine the optimal band circumference.
The mid-portion of MPA is identified, with special attention paid to the location of the pulmonary valve and branch PAs, to avoid brand PA impingement and pulmonary valve distortion.
To prevent band migration, the passageway between the aorta and the MPA is dissected. The band is passed across the transverse sinus that surrounds the pulmonary trunk.
The band is then carefully passed between the aorta and the MPA via the previous dissection site, avoiding the need to pass a clamp across the MPA and risk injuring the vessel.
The band’s marked sites are aligned along the anterior wall of MPA and snared by passing them through polyethylene tubing.
A pericardial pledget is placed beneath the loop of the snare to protect the vessel, and hem clips are used to secure the snare.
The addition or removal of hem clips reduces or increases the band’s circumference, respectively.
Occasionally, resorption of MPA folds over a few weeks reduces the restriction across the MPA, loosening the band.
As a result, a method for performing a V-shaped arteriotomy on the MPA distal to the Sino tubular junction has been described.
To avoid the risk of the band loosening later, a C-clamp is used before placing it.
The PAB is usually removed after the staged intracardiac repair is completed. The scar tissue surrounding the PAB is dissected, and the band is usually removed to reveal evidence of MPA stenosis.
This can be corrected through either resection of the stenotic segment followed by end-to-end anastomosis or vertical incision of the stenotic segment with patch augmentation.
In patients whose PA bands have been in place for several months or less, this PA plasty is often unnecessary.

Recovery After PA

Recovery from PAB varies according to the patient’s condition and the complexity of the procedure. However, some general considerations are:

Children usually stay in the hospital for a few days to a week after PAB.
Medications may be prescribed to relieve pain and prevent infection.
Follow-Up Care: Regular appointments with a pediatric cardiologist are required to monitor the child’s progress and ensure the band’s effectiveness.
Lifestyle: After PAB, most children can lead relatively normal lives with a few activity limitations. However, this may vary depending on the individual circumstances.

Benefits of a Pulmonary Artery Banding Procedure

PAB is critical for treating specific congenital heart defects, particularly those that result in excessive blood flow to the lungs.
Without this procedure, the heart’s workload can become too much, potentially leading to heart failure and other issues.
PAB protects the pulmonary vasculature by reducing excessive pulmonary blood flow, which prevents irreversible vasculature remodeling and pulmonary hypertension.
In patients with D & L transposition of the great arteries (TGA), PBA helps “train” the left ventricle in preparation for a staged arterial switch procedure.
Many children live healthy lives after having a successful PAB procedure. They may experience increased energy and fewer symptoms related to their congenital heart condition.
Regular follow-up appointments with a pediatric cardiologist are essential for monitoring the child’s progress, ensuring the band’s effectiveness, and making any necessary changes.

Complications in the case of PA Banding

The potential complications of pulmonary artery banding include:

Stenosis or distortion of one or both branch pulmonary arteries.
Variations in the function of the pulmonary valve.
Impingement of the circumflex artery.
Erosion of the band into the pulmonary artery.
A pseudoaneurysm in the pulmonary artery.
Haemolysis.
Thrombosis.
Ineffective band placement leads to irreversible changes in the pulmonary vasculature, resulting in pulmonary hypertension.
Local infection.

Prognosis of PA Banding

Successful PAB frequently results in significant improvement in cardiac hemodynamics, resolution of congestive heart failure signs/symptoms, improvement in pulmonary overflow circulation, and reduction in ventricular end-diastolic volume.

The mortality rate among PAB patients reflects the complexity of the underlying congenital heart defects rather than the procedure itself. Patients who frequently underwent PAB in preparation for a staged surgical repair may have been deemed high risk for a permanent repair. As a result, early studies reported approximately 25% mortality with PAB.

However, subsequent improvements in surgical techniques, proper timing of PAB placement, and improvements in perioperative care have significantly reduced the mortality rate by approximately 5%.

Over time, surgical techniques for PAB have evolved, resulting in better outcomes and fewer complications. Minimally invasive approaches are becoming more popular, with smaller incisions and shorter recovery times.

It is critical to recognize that both parents and children may face emotional difficulties during the diagnostic, surgical, and recovery processes. Seek help from medical personnel and support groups to successfully navigate these emotional challenges.

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