p<0.05 compared Intermittent and Traditional groups.

**Table 1.** Gross and histomorphometric RV findings in Sham, Traditional and Intermittent groups

The prototype used in this study (SILIMED, Rio de Janeiro, Brazil) represents the adult version of the small adjustable PAB system used previously in young animals (Figure 17). Its dimen‐ sions were planned to support higher pressure gradients in adolescents and adults patients considered for subpulmonary ventricle retraining. All parts of the Adjustable Banding System are made of biologically stable material (medical grade silicone).

The banding ring is a C-shaped hydraulic cuff that has three layers. The inner wall of the banding ring is formed by a very thin and flexible silicone that allows centripetal distension. Differently from the young animal prototype, the outer layer is divided in two parts, both

with TGA and failed atrial inversion, aged from 1.9 to 23 years, it took an average of 15.6 months to retrain the subpulmonary ventricle for the two-stage Jatene operation. In addition, it has been described in the literature the need for subsequent reoperations to readjust PA banding in cases where patient cannot achieve adequate LV hypertrophy. The difficulties in retraining adult myocardium with the traditional approach has stimulated several groups to propose a more physiologic protocol based on the hypothesis that intermittent systolic overload would improve the quality of subpulmonary ventricle hypertrophy. Such an approach has the appealing advantage of ventricular retraining with no collagen formation, providing a more physiologic hypertrophy. However, the time necessary to retrain these ventricles and the best way to achieve a more physiologic hypertrophy and assess the specific histologic changes involved in this process are still required. We have compared the histomorphometric changes of PAB-induced RV hypertrophy of adult goats, with the emphasis on a detailed analysis of

> **Traditional N = 6**

0.33 (0.08-0.75) 0.33 (0.08-0.83) 0.25 (0.08-0.58) 0.89

2.67 (1.00-3.58) 2.83 (1.25-8.50) 2.17 (1.75-4.75) 0.68

Mass (g/kg) 0.79 ± 0.15 1.08 ± 0.17 \* 1,24 ± 0.16 † <0.05 Water Content (%) 79.16 ± 1.28 79.67 ± 1.25 80.61 ± 1.87 0.27 Cardiomyocyte diameter (µm) 11.54 ± 0.89 12.96 ± 1.35 13.76 ± 1.68 † <0.05 Nuclei diameter (µm) 3.86 ± 0.14 4.40 ± 0.48 4.74 ± 0.71 † <0.05 Collagen percentage area (%) 2.94 ± 0.65 5.82 ± 1.91 \* 3.44 ± 1.24 # <0.05

**Intermmitent N = 6**

**p value**

the myocardium adaptation process (Table 1).

166 Cardiac Surgery - A Commitment to Science, Technology and Creativity

Cardiomyocyte Ki67+ cells (cells/ field)

Interstitial/Vessel Ki67+ cells (cells/field)

Values: means ± SD or medians (limits)

\* p<0.05 compared Traditional and Sham groups; † p<0.05 compared Intermittent and Sham groups; # p<0.05 compared Intermittent and Traditional groups.

**Sham N = 6**

**Table 1.** Gross and histomorphometric RV findings in Sham, Traditional and Intermittent groups

are made of biologically stable material (medical grade silicone).

The prototype used in this study (SILIMED, Rio de Janeiro, Brazil) represents the adult version of the small adjustable PAB system used previously in young animals (Figure 17). Its dimen‐ sions were planned to support higher pressure gradients in adolescents and adults patients considered for subpulmonary ventricle retraining. All parts of the Adjustable Banding System

The banding ring is a C-shaped hydraulic cuff that has three layers. The inner wall of the banding ring is formed by a very thin and flexible silicone that allows centripetal distension. Differently from the young animal prototype, the outer layer is divided in two parts, both

**Figure 17.** The adult banding device consists of an inflatable C-shaped hydraulic cuff (24-mm diameter) and an infla‐ tion reservoir connected hermetically to each other by a 2.0-mm diameter tube (SILIMED, Rio de Janeiro, Brazil).

consisting of 1.0-mm-thick rigid silicone each, reinforced with a polyester mesh. The outer external layer presents some small holes along the non apart borders, which are used for securing it firmly with sutures to the adventitia of the artery. This keeps the adjustable banding system from migrating distally and impinging on the pulmonary artery bifurcation. The external layer prolongs with two apart ends, planned for further adjustment of the hydraulic cuff, when placed around the artery, by suturing together the ends. The inner external layer prolongs alongside the cuff as a canoe, to keep it from deforming. The connecting tubing has 1.0 mm inner diameter. The inflation reservoir used to pump fluid to the hydraulic cuff consists of a ceramic cylindrical reservoir, with a self-sealing silicone diaphragm at the top, which keeps the banding system leak proof after repeated needle puncture of the reservoir.

The two regimens of ventricular training, traditional and intermittent, have promoted different degrees of myocardial hypertrophy. However, it was less intense and longer in adult animals than that observed previously in young goat hearts. Histomorphometric and echocardio‐ graphic data indicated that intermittent RV systolic overload promoted a harmless RV hypertrophy in adult goats during a 4-week study period. On one hand, the primary mecha‐ nism of RV mass acquisition was probably related to increased protein synthesis and cell hypertrophy rather than myocardial hyperplasia or edema. On the other hand, the traditional PAB group evolved with greater collagen production, which is one of the important mecha‐ nisms of late ventricular failure. The absence of myocardial edema and significant cell proliferation observed in that study suggests that the mass acquisition was probably related to enhanced protein synthesis, both intracellular (contractile proteins) and extracellular (matrix proteins). In the adult heart of mammals, it is generally believed that almost none of the cardiomyocytes proliferate and that the hypertrophy process functions as the fundamental adaptive response. The magnitude of cardiomyocyte hypertrophy then depends on the age at which the stimulus is produced. As predicted in an adult model, no significant cellular proliferation was observed in any cardiac segment, contrary to the findings of similar experi‐ mental studies in young animals, in which RV responds not only with hypertrophy of the myocardial fibers but also with hyperplasia of the contractile and interstitial myocardial cells. Although the intermittent group was the one least exposed to systolic overload, a more efficient RV hypertrophy was observed, just as documented previously by our studies in young goat hearts. Similarly, the hemodynamic results showed that the intermittent group could achieve greater RV-to-PA pressure gradients than the traditional group during the 4-week study period. Intermittent systolic overload mimics exercise training, which can benefit the trained myocardium with improved subendocardial perfusion. On one hand, it is likely that the mechanism of this hypertrophic process may be developed during the resting periods with ideal oxygen transport and, hence, without the collagen deposition resulting from continuous

relative diastolic hypoperfusion. On the other hand, the traditional group had deleterious effects at the end of the protocol, with more collagen deposition in the RV interstitium. The mean RV collagen area fraction of the Traditional group was significantly greater than in the Sham group (98% increase; p<0.01), and greater than that in the Intermittent group (69.2% increase; p<0.05). The histological distribution of collagen in representative animals from trained groups is demonstrated in Figure 18. This collagen deposit may be the key determinant of the impaired RV function previously observed on the same protocol. Accordingly, Le Bret and colleagues reported myocardial fibrosis associated with continuous overload and no fibrosis in their "fitness" group, during a 5-week period in adult sheep. Although the results with adjustable intermittent PAB are encouraging, it is premature to assume this as the

Adjustable Pulmonary Artery Banding http://dx.doi.org/10.5772/57117 169

**8. Adjustable PA banding and hypoplastic left heart syndrome**

More recently, bilateral PA banding has been applied to hypoplastic left heart syndrome (HLHS). The mitral and aortic valves present either with atresia or hypoplasia. This results in a situation where the left side of the heart is completely unable to support systemic circulation, though the right side of the heart is typically normally developed. Blood returning from the lungs to the LA must pass through an atrial septal defect to the right side of the heart. The RV must then pump blood both to the lungs (via the pulmonary trunk) and out to the body (via a patent ductus arteriosus). The patent *Ductus Arteriosus*, a normal structure in the fetus, is often the only pathway through which blood can reach the body from the heart. When the *Ductus Arteriosus* begins to close, as it typically does in the first days of life, the blood flow to the body will severely diminish, resulting in dangerously low blood flow to vital organs and leading to shock. Without treatment, HLHS is uniformly fatal, often within the first hours or days of life. The most commonly pursued treatment for HLHS is "staged reconstruction" in which a series of operations, usually three, are performed to reconfigure the child's cardio‐ vascular system to be as efficient as possible, despite the lack of an adequate LV. The first operation in the staged approach is the Norwood operation and is typically performed in the first week of life. With the Norwood operation, the RV becomes the systemic or main ventricle pumping to the body, and a systemic-to-pulmonary shunt aims redirectioning circulatory pathways to protect the pulmonary vasculature from excessive blood flow and optimize systemic organ flows. However, some overloading of the systemic right ventricle still persists after this operation. Also, such major surgical procedure is usually performed in the neonatal period (sometimes in a low-birth weight patient and unfavorable anatomy), which may result in sub-optimal neurological outcomes in the long-term. Because of the extensive reconstruction of the aorta that must be done, this operation is one of the most challenging heart surgeries in Pediatrics. This traditional surgical approach of newborns with HLHS is complex and continues to have significant mortality compared with other neonatal cardiac operations.

An alternative approach for palliation of hypoplastic left heart in the neonatal period has been stenting the arterial duct in combination with branch PA banding and atrial septostomy, as needed. The so called hybrid stage I palliation has been considered the preferred therapeutic

definitive solution for adult myocardium retraining.

**Figure 18.** Photomicrographies of the right ventricular myocardium from four representative animals, two from the Traditional (A and B) and two from the Intermittent (C and D) group, after four weeks of systolic overload. Panels A and B show a higher density and intensity of collagen staining (red fibers around individual cardiomyocytes- endomy‐ sial fibrosis) than that in panels C and D. Sirius-red staining, objective magnification-20X.

relative diastolic hypoperfusion. On the other hand, the traditional group had deleterious effects at the end of the protocol, with more collagen deposition in the RV interstitium. The mean RV collagen area fraction of the Traditional group was significantly greater than in the Sham group (98% increase; p<0.01), and greater than that in the Intermittent group (69.2% increase; p<0.05). The histological distribution of collagen in representative animals from trained groups is demonstrated in Figure 18. This collagen deposit may be the key determinant of the impaired RV function previously observed on the same protocol. Accordingly, Le Bret and colleagues reported myocardial fibrosis associated with continuous overload and no fibrosis in their "fitness" group, during a 5-week period in adult sheep. Although the results with adjustable intermittent PAB are encouraging, it is premature to assume this as the definitive solution for adult myocardium retraining.

#### **8. Adjustable PA banding and hypoplastic left heart syndrome**

Although the intermittent group was the one least exposed to systolic overload, a more efficient RV hypertrophy was observed, just as documented previously by our studies in young goat hearts. Similarly, the hemodynamic results showed that the intermittent group could achieve greater RV-to-PA pressure gradients than the traditional group during the 4-week study period. Intermittent systolic overload mimics exercise training, which can benefit the trained myocardium with improved subendocardial perfusion. On one hand, it is likely that the mechanism of this hypertrophic process may be developed during the resting periods with ideal oxygen transport and, hence, without the collagen deposition resulting from continuous

168 Cardiac Surgery - A Commitment to Science, Technology and Creativity

**Figure 18.** Photomicrographies of the right ventricular myocardium from four representative animals, two from the Traditional (A and B) and two from the Intermittent (C and D) group, after four weeks of systolic overload. Panels A and B show a higher density and intensity of collagen staining (red fibers around individual cardiomyocytes- endomy‐

sial fibrosis) than that in panels C and D. Sirius-red staining, objective magnification-20X.

More recently, bilateral PA banding has been applied to hypoplastic left heart syndrome (HLHS). The mitral and aortic valves present either with atresia or hypoplasia. This results in a situation where the left side of the heart is completely unable to support systemic circulation, though the right side of the heart is typically normally developed. Blood returning from the lungs to the LA must pass through an atrial septal defect to the right side of the heart. The RV must then pump blood both to the lungs (via the pulmonary trunk) and out to the body (via a patent ductus arteriosus). The patent *Ductus Arteriosus*, a normal structure in the fetus, is often the only pathway through which blood can reach the body from the heart. When the *Ductus Arteriosus* begins to close, as it typically does in the first days of life, the blood flow to the body will severely diminish, resulting in dangerously low blood flow to vital organs and leading to shock. Without treatment, HLHS is uniformly fatal, often within the first hours or days of life. The most commonly pursued treatment for HLHS is "staged reconstruction" in which a series of operations, usually three, are performed to reconfigure the child's cardio‐ vascular system to be as efficient as possible, despite the lack of an adequate LV. The first operation in the staged approach is the Norwood operation and is typically performed in the first week of life. With the Norwood operation, the RV becomes the systemic or main ventricle pumping to the body, and a systemic-to-pulmonary shunt aims redirectioning circulatory pathways to protect the pulmonary vasculature from excessive blood flow and optimize systemic organ flows. However, some overloading of the systemic right ventricle still persists after this operation. Also, such major surgical procedure is usually performed in the neonatal period (sometimes in a low-birth weight patient and unfavorable anatomy), which may result in sub-optimal neurological outcomes in the long-term. Because of the extensive reconstruction of the aorta that must be done, this operation is one of the most challenging heart surgeries in Pediatrics. This traditional surgical approach of newborns with HLHS is complex and continues to have significant mortality compared with other neonatal cardiac operations.

An alternative approach for palliation of hypoplastic left heart in the neonatal period has been stenting the arterial duct in combination with branch PA banding and atrial septostomy, as needed. The so called hybrid stage I palliation has been considered the preferred therapeutic approach in high-risk neonates. However, fine adjustments of the amount of pulmonary blood flow, which is a critical issue, has proved to be a particularly difficult aspect of the procedure. This can be readily explained when it is recalled that Poiseuille's law predicts that blood flow is related to the fourth power of the radius of the vessel. Therefore, a minor alteration in diameter will have a large impact on flow and pressure gradient across the band site. Generally, the bands are surgically adjusted (tighten or loosened), based on pressure measurements and the arterial oxygen saturation monitoring. A systolic pressure in the distal pulmonary artery less than half of the systemic pressure and an arterial oxygen saturation of 75%-85% usually reflect an adequate balance between the pulmonary and systemic blood flow. This may be readily achieved in the operating room, with an open chest and under artificial conditions. However, in the postoperative period, which may be quite unpredictable, the fixed pulmonary bandings do not allow for fine adjustments according to the underlying clinical needs of the patient. Moreover, in order to avoid hypoxemia as the infant rapidly grows up, the balance between the pulmonary and systemic blood flows should be adjusted, which is impossible with the fixed bands. To deal with these problems, we devised a mini banding device that allows for fine percutaneous adjustments of the pulmonary blood flow in the neonate (Figure 19). The banding ring is a C-shaped hydraulic cuff, with 5 mm width, and a rigid outer layer, reinforced with a polyester mesh, which keep it from deforming centrifugally. It can be used in pulmonary arteries varying from 3 mm to 6 mm internal diameter range.

of the patients: hypoxemia is, for instance, managed by unfastening the pulmonary artery banding circumference. Once the adjustable banding ring is placed around the PA's and the inflation reservoirs left in the infraclavicular subcutaneous tissue, the degree of banding rings constriction is adjusted after sternal closure (Figure 20). Each band is inflated with saline solution to decrease arterial oxygen saturation to the 75%-85% range, while breathing under

Adjustable Pulmonary Artery Banding http://dx.doi.org/10.5772/57117 171

**Figure 20.** Inflating reservoirs positioned in the infraclavicular area (arrows), one for each pulmonary artery for inde‐

We have performed Hybrid Stage I palliation for HLHS using the adjustable PA band (APAB group) in 3 patients (1.8 kg - 2.8 kg) and traditional bands (TPAB group) in 3 patients (2.0 kg - 3.3 kg). The babies were followed closely with serial echocardiographic assessment every week. During inter-stage 1-2, several additional percutaneous adjustments of the PA's banding systems were necessary to maintain the arterial oxygen saturation in the recommended range according to somatic growth. Figure 21 shows the O2 saturation behavior of both groups during

a 30% inspired oxygen fraction.

pendent percutaneous blood flow adjustment.

interstage 1-2 period.

**Figure 19.** The adjustable pulmonary artery banding system (SILIMED, Rio de Janeiro, Brazil) used for Hybrid Stage I palliation for HLHS.

This innovative percutaneous mini adjustable banding system permits a fine control of the pulmonary blood flow by increasing or decreasing accurately the cross-sectional diameter of the pulmonary arteries. Therefore, it is adjusted according to the underlying clinical conditions of the patients: hypoxemia is, for instance, managed by unfastening the pulmonary artery banding circumference. Once the adjustable banding ring is placed around the PA's and the inflation reservoirs left in the infraclavicular subcutaneous tissue, the degree of banding rings constriction is adjusted after sternal closure (Figure 20). Each band is inflated with saline solution to decrease arterial oxygen saturation to the 75%-85% range, while breathing under a 30% inspired oxygen fraction.

approach in high-risk neonates. However, fine adjustments of the amount of pulmonary blood flow, which is a critical issue, has proved to be a particularly difficult aspect of the procedure. This can be readily explained when it is recalled that Poiseuille's law predicts that blood flow is related to the fourth power of the radius of the vessel. Therefore, a minor alteration in diameter will have a large impact on flow and pressure gradient across the band site. Generally, the bands are surgically adjusted (tighten or loosened), based on pressure measurements and the arterial oxygen saturation monitoring. A systolic pressure in the distal pulmonary artery less than half of the systemic pressure and an arterial oxygen saturation of 75%-85% usually reflect an adequate balance between the pulmonary and systemic blood flow. This may be readily achieved in the operating room, with an open chest and under artificial conditions. However, in the postoperative period, which may be quite unpredictable, the fixed pulmonary bandings do not allow for fine adjustments according to the underlying clinical needs of the patient. Moreover, in order to avoid hypoxemia as the infant rapidly grows up, the balance between the pulmonary and systemic blood flows should be adjusted, which is impossible with the fixed bands. To deal with these problems, we devised a mini banding device that allows for fine percutaneous adjustments of the pulmonary blood flow in the neonate (Figure 19). The banding ring is a C-shaped hydraulic cuff, with 5 mm width, and a rigid outer layer, reinforced with a polyester mesh, which keep it from deforming centrifugally. It can be used

170 Cardiac Surgery - A Commitment to Science, Technology and Creativity

in pulmonary arteries varying from 3 mm to 6 mm internal diameter range.

**Figure 19.** The adjustable pulmonary artery banding system (SILIMED, Rio de Janeiro, Brazil) used for Hybrid Stage I

This innovative percutaneous mini adjustable banding system permits a fine control of the pulmonary blood flow by increasing or decreasing accurately the cross-sectional diameter of the pulmonary arteries. Therefore, it is adjusted according to the underlying clinical conditions

palliation for HLHS.

**Figure 20.** Inflating reservoirs positioned in the infraclavicular area (arrows), one for each pulmonary artery for inde‐ pendent percutaneous blood flow adjustment.

We have performed Hybrid Stage I palliation for HLHS using the adjustable PA band (APAB group) in 3 patients (1.8 kg - 2.8 kg) and traditional bands (TPAB group) in 3 patients (2.0 kg - 3.3 kg). The babies were followed closely with serial echocardiographic assessment every week. During inter-stage 1-2, several additional percutaneous adjustments of the PA's banding systems were necessary to maintain the arterial oxygen saturation in the recommended range according to somatic growth. Figure 21 shows the O2 saturation behavior of both groups during interstage 1-2 period.

**Author details**

Renato S. Assad

**References**

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Heart Institute University of Sao Paulo School of Medicine, Brazil

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[1] Bishop SP & Cole CR – Production of Externally Controlled Progressive Pulmonis

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[2] Assad RS, Cardarelli M, Abduch MCD, Aiello VD, Maizato M, Jatene A.D. Banda‐ gem Reversível do Tronco Pulmonar: Modelo Experimental para Preparo Rápido do

[3] Jacobson JH & McAllister FF. A method for the controlled occlusion of a larger blood

[4] Edmunds LHJr, Rudy LW, Heymann MA, Boucher JK. An adjustable pulmonary ar‐

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[7] Jonas RA, Giglia TM, Sanders SP, Wernovsky G, Nadal-Ginard B, Mayer JE Jr, Casta‐ neda AR. Rapid Two-Stage Arterial Switch for Transposition of the Great Arteries and Intact Ventricular Septum beyond the Neonatal Period. Circulation. 1989; 80:

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**Figure 21.** Traditional PA banding group evolved with progressive decrease of oxygen saturation during interstage 1-2, while the group using adjustable PA bands maintained more stable arterial oxygen saturation according to so‐ matic growth.

In the APAB group, all patients reached stage 2 operation, and one of them has already completed Fontan circulation at 2 years of age, while in the TPAB group, two cases underwent the stage 2 operation and one patient died just before stage 2 operation (pulmonary infection). This small series of HLHS cases demonstrated that customization of the pulmonary blood flow seemed to result in a more precise balance between the pulmonary and systemic circulations during the interstage 1-2 period. The use of adjustable PA bands in the stage-1 hybrid proce‐ dure for HLHS can provide a more stable clinical condition, according to the rapid somatic growth and underlying clinical needs of the patient. However, the calibration of the banding cuffs was sometimes difficult to achieve, due to the extreme complexity of the continuously changing relationship between systemic and pulmonary vascular resistance, with the depend‐ ency upon several inter-related variable such as the values of the arterial pO2, pCO2, pH, hemoglobin, cardiac output, level of sedation, use of peripheral and/or pulmonary vasodila‐ tors, etc. Nevertheless, fine and reversible adjustments could be performed as many times as needed, both in acute and ambulatory settings, avoiding further surgical interventions. The use of this innovative banding system seemed to result in a more predictable postoperative course, and in a more stable patient, which is highly desirable for the comprehensive phase II operation. A concern with any PAB technique or device, including ours, is the possibility of causing vessel distortions or stenoses, which may have a deleterious impact for subsequent cavo-pulmonary operations. Fortunately, the scar tissue surrounding the banding devices was minimal in our patient and did not result in any of these complications. The cases electively submitted to the "comprehensive" stage II surgical palliation showed the anatomy of the pulmonary arteries well preserved with no distortions.

In summary, the use of our innovative mini PAB system allowed for a fine control of the pulmonary blood flow in neonates with HLHS undergoing phase I palliation. This customi‐ zation of the pulmonary blood flow according to the underlying clinical needs of an infant with rapid somatic growth seemed to result in a more precise balance between the pulmonary and systemic circulations during the inter-stage period.

#### **Author details**

Renato S. Assad

Heart Institute University of Sao Paulo School of Medicine, Brazil

#### **References**

**APAB TPAB** 

**Figure 21.** Traditional PA banding group evolved with progressive decrease of oxygen saturation during interstage 1-2, while the group using adjustable PA bands maintained more stable arterial oxygen saturation according to so‐

In the APAB group, all patients reached stage 2 operation, and one of them has already completed Fontan circulation at 2 years of age, while in the TPAB group, two cases underwent the stage 2 operation and one patient died just before stage 2 operation (pulmonary infection). This small series of HLHS cases demonstrated that customization of the pulmonary blood flow seemed to result in a more precise balance between the pulmonary and systemic circulations during the interstage 1-2 period. The use of adjustable PA bands in the stage-1 hybrid proce‐ dure for HLHS can provide a more stable clinical condition, according to the rapid somatic growth and underlying clinical needs of the patient. However, the calibration of the banding cuffs was sometimes difficult to achieve, due to the extreme complexity of the continuously changing relationship between systemic and pulmonary vascular resistance, with the depend‐ ency upon several inter-related variable such as the values of the arterial pO2, pCO2, pH, hemoglobin, cardiac output, level of sedation, use of peripheral and/or pulmonary vasodila‐ tors, etc. Nevertheless, fine and reversible adjustments could be performed as many times as needed, both in acute and ambulatory settings, avoiding further surgical interventions. The use of this innovative banding system seemed to result in a more predictable postoperative course, and in a more stable patient, which is highly desirable for the comprehensive phase II operation. A concern with any PAB technique or device, including ours, is the possibility of causing vessel distortions or stenoses, which may have a deleterious impact for subsequent cavo-pulmonary operations. Fortunately, the scar tissue surrounding the banding devices was minimal in our patient and did not result in any of these complications. The cases electively submitted to the "comprehensive" stage II surgical palliation showed the anatomy of the

In summary, the use of our innovative mini PAB system allowed for a fine control of the pulmonary blood flow in neonates with HLHS undergoing phase I palliation. This customi‐ zation of the pulmonary blood flow according to the underlying clinical needs of an infant with rapid somatic growth seemed to result in a more precise balance between the pulmonary

pulmonary arteries well preserved with no distortions.

172 Cardiac Surgery - A Commitment to Science, Technology and Creativity

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*Edited by Miguel Angel Maluf and Paulo Roberto Barbosa Evora*

In this book it is shown how this specialty has evolved over the past 20 years, with significant advances in diagnosis and palliative and definitive techniques for correction of cardiovascular diseases. The book contains 10 cahpters, which are showing the classical adult and pediatric cardiac surgery.

Cardiac Surgery - A Commitment to Science, Technology and Creativity

Cardiac Surgery

A Commitment to Science,

Technology and Creativity

*Edited by Miguel Angel Maluf* 

*and Paulo Roberto Barbosa Evora*

Photo by ChaNaWiT / iStock