General Thoracic and Cardiovascular Surgery

https://doi.org/10.1007/s11748-021-01674-6

ORIGINAL ARTICLE

A valuable echocardiographic indicator for the optimal tightness

of bilateral pulmonary artery banding
Hiroshi Koshiyama1   · Takamasa Takeuchi1 · Junko Katagiri1 · Yusuke Iwata1

Received: 23 November 2020 / Accepted: 14 June 2021

© The Japanese Association for Thoracic Surgery 2021

Abstract
Objectives  The optimal tightness of bilateral pulmonary artery banding (BPAB) is considered to balance not only systemic-
to-pulmonary blood flow but also each pulmonary blood flow, which is still challenging. To achieve them, we adopt the end-
diastolic velocity (EDV) to the peak systolic velocity (PSV) ratio at BPAB with intraoperative epicardial echocardiography.
We evaluated the usefulness of the EDV to PSV ratio and the patient outcomes.
Methods  34 patients underwent BPAB with this indicator and using a looped polytetrafluoroethylene suture. The PSV and
the EDV to PSV ratio with echocardiography were measured in the intraoperative, early postoperative and late postoperative
period. Lung perfusion scintigraphy was performed to quantify flow to each lung.
Results  There were 3 early deaths (< 30 days). Two patients required re-BPAB due to hypoxia. The intraoperative EDV to
PSV ratios in the right and left were almost equal (0.50 ± 0.07 versus 0.51 ± 0.06, P = 0.73). There was no significant differ-
ence in the right and left EDV to PSV ratios throughout the postoperative course. The right PSV was smaller than the left
PSV due to the Doppler angle intraoperatively (2.78 ± 0.57 versus 3.02 ± 0.50, P = 0.030). In addition, the PSV changed
significantly until the late postoperative period (P < 0.001). Lung perfusion scintigraphy revealed only two patients had
perfusion abnormalities.
Conclusions  Our clinical outcomes are satisfactory with low early mortality and a low rate of re-BPAB. The EDV to PSV
ratio can be a reliable indicator to assess flow distribution to each lung and may be a valuable adjunct to achieve balanced
systemic to pulmonary flow.

Keywords  Bilateral pulmonary artery banding · Echocardiography · Single ventricle

Introduction The hemodynamics after the BPAB has a diastolic pulmo-

Bilateral pulmonary artery banding (BPAB) has been widely
performed as an initial palliation for patients with ductal-
dependent systemic circulation. Several centers reported
BPAB improved the outcomes [1–3]. However, a standard
method to obtain appropriate tightness has not been estab-
lished and adjustment of the tightness is technically chal-
lenging due to the small branch pulmonary artery. Further-
more, not only balanced systemic-to-pulmonary blood flow
but also nearly equal flow distribution to each lung should be
considered to achieve the optimal tightness of the BPAB [4].
* Hiroshi Koshiyama
hkoshi.md@gmail.com
1
Department of Pediatric Cardiac Surgery, Children’s
Medical Center, Gifu Prefectural General Medical Center,
4‑6‑1 Noishiki Gifu, Gifu 500‑8716, Japan
nary runoff as seen with systemic to pulmonary artery shunt
and persistent ductus arteriosus (PDA) [4]. In neonates, a
PDA in patients with low pulmonary arterial pressure have
continuous left-to-right shunt with peak flow velocity and
the end-diastolic flow velocity (EDV) to the peak systolic
flow velocity (PSV) ratio greater than 0.5 has been recently
reported as one of the indicators to assess non-hemody-
namically significant or restrictive PDA with transthoracic
echocardiography which was related to magnetic resonance
imaging statistically [5–9].
In our hospital, we have considered the EDV to the PSV
ratio at both banding sites with intraoperative epicardial
echocardiography as one of the indicators to achieve the
optimal tightness in the right pulmonary artery banding
(RPAB) and the left pulmonary artery banding (LPAB). We
evaluated our clinical outcomes and the usefulness of the
EDV to PSV ratio.

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 General Thoracic and Cardiovascular Surgery

Patients and methods

The Gifu Prefectural General Medical Center institutional

review board approved the present retrospective study; the
need for informed consent was waived. We retrospectively
reviewed the medical records, operative notes, echocar-
diographic findings, 99mTc macroaggregated albumin lung
perfusion scan of 34 patients who underwent BPAB using
the looped expanded polytetrafluoroethylene suture (CV-
0, WL Gore, Newark, DE, USA) with the indicator of the
EDV to PSV ratio in our hospital between October 2009
and February 2019. At the time of BPAB, their age and
weight were 9.0 ± 8.3 days and 2.5 ± 0.4 kg, respectively.
25 patients had functionally single ventricle physiology.
11 patients had hypoplastic left heart syndrome and 14
patients had hypoplastic left heart syndrome variant. There
were 9 patients with biventricular physiology. 6 patients
had interrupted aortic arch and 3 patients had Coarctation
of the Aorta. The indications for the patients with biven-
tricular physiology were left ventricular outflow obstruc-
tion (n = 6) and unstable hemodynamics(n = 3).

Fig. 1  A an expanded polytetrafluoroethylene suture (CV-0) is folded

Surgical technique
The bilateral pulmonary artery banding was performed
using CV-0. CV-0 was folded and sutured at BW + 10 mm
and BW + 11 mm from the folded point to make marks and
a loop with 6–0 monofilament sutures (Fig. 1A). The frac-
tion of inspiratory oxygen was kept at 0.21 during opera-
tion. Through a median sternotomy, both pulmonary arter-
ies were dissected minimally and encircled with the looped
CV-0. Then, both ends of CV-0 were passed through the
loop. The top of the loop was ligated left the space of
the double CV-0, which was passed through a 10  mm
long silicone tube of 1 mm internal diameter (Fig. 1B).
The silicone tube was pushed down to tighten the branch
pulmonary artery until the mark of BW + 11 mm. During
adjustment, there was no need to fix it because the posi-
tion of the silicone tube was naturally fixed by the friction
between the silicone tube and the double CV-0. Firstly,
the tightness of both bands was adjusted to achieve par-
tial pressure of arterial oxygen (PaO2) of 35–40 mmHg,
arterial oxygen saturation (SaO2) of 70–80. Then intra-
operative epicardial echocardiography was performed to
assess the color flow mapping, the PSV and the EDV to
PSV ratio across both bands. The optimal tightness dur-
ing the operation was decided by considering these fac-
tors and other factors such as the patient’s condition, and
the systemic blood pressure comprehensively. The PSV of
3.0–3.5 m/s was our target while systolic arterial pressure
and sutured to make marks and a loop. B the branch pulmonary artery
is encircled with the looped CV-0 and both ends of CV-0 are passed
through the loop and the small silicone tube. C a small vascular clip
is applied to the silicone tube to fix it after adjustment
was 60–65 mmHg. The right and left EDV to PSV ratios
were made as equal as possible to maintain a balanced
distribution of pulmonary blood flow. In addition, the
EDV to PSV ratio of 0.4–0.6 was considered as one of
the indicators from our experience. Small vascular clips
were applied to both silicone tubes to fix it after adjust-
ment (Fig. 1C).
Echocardiography and lung perfusion
scintigraphy
All patients received echocardiography at the time of the
intraoperative period, the early postoperative period which
was within postoperative days 2 in the intensive care unit
after the operation and the late postoperative period which
was after postoperative days 7. Epicardial echocardiography
was performed intraoperatively and transthoracic echocar-
diography was performed postoperatively to assess the PSV
and the EDV to PSV ratio using continuous-wave Doppler
(Fig. 2A). Color Doppler mapping was also used to visualize
the narrowest point and the tightness of BPAB (Fig. 2B).
Lung perfusion scintigraphy was performed to quan-
tify pulmonary blood flow to each lung at the time of the
late operative period. The measurement of the right lung

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General Thoracic and Cardiovascular Surgery
Fig. 2  A epicardial echocardiography during operation. Color Dop-
pler mapping visualizing the narrowest point and the tightness of
bilateral pulmonary artery bandings. (RPA right pulmonary artery;
LPA left pulmonary artery; MPA main pulmonary artery.) B meas-
urement of the peak systolic flow velocity and the end-diastolic flow
velocity across the band by continuous-wave Doppler
of greater than 75% or smaller than 25% were indicated
perfusion abnormalities [10].
Statistical analysis
Data were expressed as mean ± standard deviation and
range. The PSV, the EDV to PSV ratio and body weight
between each period were compared using Wilcoxon
signed-rank test. The PSV and the EDV to PSV ratio
in between the RPAB and the LPAB intraoperatively
were compared using Wilcoxon signed-rank test. P val-
ues < 0.05 were considered significant. All data analyzes
were performed using JMP 14 software (SAS Institute,
Cary, NC).
Results
Overall outcomes
There were three early deaths (< 30 days) and one late
death before the second stage operation: necrotizing enter-
ocolitis (n = 1), sudden death (n = 2), and sepsis (n = 1).
These patients were critically ill before the BPAB.
Two patients (5.8%) required re-BPAB due to hypoxia
(n = 2, postoperative days 0, 9). In the first patient, intra-
operative echocardiography assessed the EDV to PSV ratio
of 0.75 in the RPAB and 0.65 in the LPAB which were
higher than our target ratio. The oxygen saturation was
gradually decreased as time passes and reached around
60% on postoperative days 9. After re-BPAB on the day,
the EDV to PSV ratio was 0.42 in the RPAB and 0.52 in
the LPAB, resulting in a stable postoperative course. In
the second patient, intraoperative assessment of the EDV
to PSV ratio was 0.57 in the RPAB and 0.51 in the LPAB
with stable hemodynamics. However, oxygen saturation
was decreased after closing the pericardium and chest.
After entering ICU, re-BPAB was performed by loosen-
ing the bands and covering the heart with a 0.1-mm thick
expanded polytetrafluoroethylene membrane instead of
closing the pericardium to prevent the silicone tubes from
being compressed.
In the late postoperative period, five patients required
transcatheter balloon angioplasty at the BPAB site because
of perfusion abnormalities due to compression of the
BPAB site (n = 2, postoperative days 44, 56), decreased
right upper lobe perfusion due to the RPAB migration
(n = 1, postoperative days 79) and hypoxia due to body
weight gain (n = 2, postoperative days 64 and 136) before
the second stage operation. In these patients, the early
postoperative courses were stable with good hemody-
namics and the targeted oxygen saturations. Transcath-
eter balloon angioplasty was successfully performed in all
patients and improved hypoxia or pulmonary flow distribu-
tion. The data of the echocardiography and lung perfusion
scintigraphy were shown in Tables 1 and 2. The ESV and
the EDV to PSV could not be measured in some patients
because the banding sites were extremely narrow or the
echocardiographic image qualities were poor. In patient
1, the body weight was 1.5 kg at the BPAB operation.
The oxygen saturation was around 85% after the BPAB.
However, the oxygen saturation was gradually decreased
to 60% as the patient body weight was gradually increased
to 2.0 kg. Therefore, Transcatheter balloon angioplasty
was performed on postoperative days 64. In patient 2, the
EDV/PSVs at the BPAB site were well balanced intraop-
eratively. However, the postoperative left EDV/PSV was
slightly higher than the intraoperative left EDV/PSV. The
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 General Thoracic and Cardiovascular Surgery

Table 1  Intraoperative and early Patient Intraoperative epicardial echocardiography Postoperative transthoracic echocardiography
postoperative echocardiographic
data in patients who required Right Left Right Left
transcatheter balloon
angioplasty PSV EDV/PSV PSV EDV/PSV POD PSV EDV/PSV PSV EDV/PSV

1 1.70 0.47 2.70 0.37 0 2.30 0.52 2.90 0.48

2 3.60 0.42 2.80 0.46 1 2.70 0.26 4.30 0.51
3 3.72 0.33 2.89 0.43 0 3.49 0.46 NA NA
4 3.11 0.50 2.57 0.45 1 2.92 0.45 2.63 0.38
5 2.02 0.36 2.05 0.39 0 3.24 0.61 2.00 0.44

PSV peak systolic velocity, EDV end-diastolic velocity, POD postoperative day, NA not available

Table 2  Echocardiographic data and lung perfusion scintigraphy before and after balloon angioplasty in patients who required transcatheter bal-
loon angioplasty
Patient POD Reason Before balloon angioplasty After balloon angioplasty
Transthoracic echocardiography Lung perfu- Transthoracic echocardiography Lung perfu-
sion scintig- sion scintig-
raphy raphy
Right Left Right Left
PSV EDV/PSV PSV EDV/PSV Right Left PSV EDV/PSV PSV EDV/PSV Right Left

1 64 Hypoxia 3.38 0.51 3.07 0.51 45 55 NA NA NA NA 49.1 50.9

2 56 Left PS 5.3 0.56 3 0.66 73.3 26.7 4.68 0.42 4.2 0.5 62.5 37.5
3 79 Right PS 4.3 0.58 NA NA 28.9 71.1 4.1 0.48 4.7 0.46 44.5 55.5
4 136 Hypoxia NA NA NA NA 47.3 52.7 NA NA NA NA 42.3 57.7
5 44 Right PS NA NA 3.9 0.48 20.6 79.4 3.8 0.42 4.1 0.43 46.2 53.8

POD postoperative day, PSV peak systolic velocity, EDV end-diastolic velocity, PS pulmonary stenosis, NA not available

silicone tube could be compressed by closing the peri-
cardium and the chest at the LPAB site, which could nar-
row the LPAB site. In patient 5, the cause was similar to
patient 2. In patient 3, the right EDV/PSV was within our
target intraoperatively and postoperatively. In addition, the
lung perfusion scintigraphy showed 42% in the right lung
and 58% in the left lung on postoperative days 15 which
was acceptable. The patient has performed the PDA stent
with the BPAB and the PDA stent gradually narrowed.
The transcatheter balloon angioplasty for the PDA stent
was planned. Before the angioplasty, the lung perfusion
scintigraphy was performed and showed 28% in the right
lung with the decreased right upper lobe perfusion on
postoperative days 79 due to the migration of the RPAB.
Therefore, the balloon angioplasty for the RPAB site was
performed concomitantly with it. In patient 4, the body
weight was 2.2 kg at the BPAB operation. The oxygen
saturation was gradually decreased to 60% as the patient
body weight was gradually increased to 4.6 kg after a long
waiting time. Therefore, Transcatheter balloon angioplasty
was performed on postoperative days 136.
The mean circumferences of the band were 12.8 ± 1.1 mm
in RPAB and 12.7 ± 1.0 in LPAB. Ductal stenting was
performed in 7 patients (20%). 27 patients had prostaglan-
din E1 infusion to maintain PDA. One patient required the
main pulmonary artery to descending aorta grafting due to
PDA obstruction.
22 patients progressed to the second stage procedure,
except for 5 patients with chromosomal abnormalities or
multiple extracardiac abnormalities. The waiting time was
98.1 ± 82 days. The remaining 3 patients are waiting for the
second stage procedure.
Echocardiographic assessment of PSV and EDV
to PSV ratio
Echocardiographic data could be reviewed from medical
records in all patients.
The early postoperative period and the late postoperative
period were 0.38 ± 0.66 and 23.1 ± 13.9 days, respectively.
Bodyweight at the time of the late postoperative period was
2.62 ± 0.34 which was almost equal to body weight at the
time of BPAB (P = 0.52).
The intraoperative PSV was 2.78 ± 0.57 in the RPAB
and 3.02 ± 0.50 in the LPAB (Fig. 3A). The right PSV was
smaller than the left PSV (P = 0.030) because it was difficult

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General Thoracic and Cardiovascular Surgery
Fig. 3  Intraoperative measurement of the peak systolic flow velocity
(A) and the end diastolic to systolic velocity ratio (B) (EDV end-dias-
tolic flow velocity, PSV peak systolic flow velocity)
to obtain the correct Doppler angle at the RPAB, resulting in
underestimation of the velocity [4]. The intraoperative EDV
to PSV ratios in the RPAB and LPAB were 0.50 ± 0.07 and
0.51 ± 0.06, respectively (Fig. 3B), which were within our
target and almost equal (P = 0.73).
The right and left PSV at the time of the early postop-
erative period were almost equal to the intraoperative PSV
(P = 0.12 in the RPAB and P = 0.47 in the LPAB) (Fig. 4).
However, the right and left PSV at the time of the late post-
operative period was significantly greater than the PSV at
the time of the intraoperative period (P < 0.001 in the RPAB
and P < 0.001 in the LPAB) although body weights at the
time of both periods were almost equal. On the other hand,
there were no significant differences between the right and
left EDV to PSV ratios among the three periods (Fig. 5).
Pulmonary blood flow distribution
Lung perfusion scintigraphy was performed in 23 patients
on 49.6 ± 60.9 days. The right and left lung perfusion ratios
were 53.0 ± 13.5 and 46.9 ± 13.5, respectively. Only two
patients had perfusion abnormalities, while most of them
Fig. 4  Serial changes of the right peak systolic flow velocity (A) and
the left peak systolic flow velocity (B)
had balanced distribution to the right and left pulmonary
arteries.
Three patients required balloon angioplasty due to perfu-
sion abnormalities (n = 2) and decreased right upper lobe
perfusion (n = 1) in the late postoperative period.
Comment
BPAB may improve the clinical outcomes for patients with
ductal-dependent systemic circulation compared to surgery
requiring cardiopulmonary bypass support in the early neo-
natal period as reported by several centers [1–3]. However,
the optimal tightness is technically challenging because
a standard method to obtain the optimal tightness during
BPAB have not been established, resulting in high mortal-
ity (26%, 30%) after BPAB [11, 12]. In addition, the reason
for the high mortality may be related to the hemodynamics
after the BPAB as seen in Blalock-Taussig shunts, in which
mortality is also high [13].
The indicators have been developed to assess the opti-
mal tightness of BPAB. In general, PaO2 and SaO2 are
used because the pulmonary-to-systemic flow ratio can be
predicted from them. However, PaO2 and SaO2 are not
reliable in the presence of impaired alveolar gas exchange
due to wet lungs and unstable circulation. Furthermore, the
13

Fig. 5  Serial changes of the right EDV to PSV ratio (A) and the left
EDV to PSV ratio (B). (EDV end-diastolic flow velocity, PSV peak
systolic flow velocity)
ratio of fetal hemoglobin affects the correlation between
PaO2 and SaO2. Therefore, the target of SaO2 had a rela-
tively wide range between 75 and 85% [4] or 70 and 80%
[14] as well as 70 and 80 in the present study. In addition,
Fig. 6  Epicardial echocardiographic assessment of both pulmo-
nary artery banding (PAB). Dotted lines show echo beams. In the
right PAB, the actual flow velocity (­VR1, black arrow) was under-
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General Thoracic and Cardiovascular Surgery
PaO2 and SaO2 are not available in patients with biven-
tricular physiology.
Some surgeons empirically use a diameter of 3 and
3.5 mm without measurement of echocardiography [14, 15].
However, the fine adjustment is often required to obtain the
optimal tightness with echocardiography from the initial cri-
terion [2–4, 16] because the branch pulmonary artery sizes
are different between the right and left pulmonary artery
and dependent on patients. If the external circumference
restricted by the band was the same, the internal circumfer-
ence might be different, because the internal circumference
is affected by the degree of the tightness which can create
the protrusion of the pulmonary artery wall. In addition,
pulse wave Doppler assessment is more important than its
actual size to evaluate its hemodynamic effect as reported
in patients with PDA [17]. The PSV at the BPAB is widely
used as one of the indicators to achieve the fine adjustment
of the tightness intraoperatively as used in the main pulmo-
nary artery banding [2–4, 16]. There are some drawbacks,
while the PSV is certainly useful to assess the gradients
across the BPAB. First, the PSV is strongly affected by the
systemic arterial pressure and the branch pulmonary arte-
rial pressure, because the measurement is reflected in the
gradient between the systolic systemic arterial pressure and
the systolic branch pulmonary arterial pressure. The target
of the PSV has been reported as 3.0 or 3.5 m/s although the
systolic systemic arterial pressure is not discussed simulta-
neously [2–4, 16]. Kitahori. et al. reported that their criterion
was greater than 3 m/s but the range of 2 to 3 m/s was often
acceptable [18], which indicated the PSV was affected by the
systolic systemic arterial pressure of the patient as the PSV
significantly changed through the postoperative course in
the present study. Secondly, the correct measurement of the
PSV in the RPAB is challenging and technically demand-
ing, because the Doppler angle is important for the precise
measurement of the PSV. The measured right flow velocity
­(VR2) describes the following equation. ­VR2 = ­VR1 × cosθ
estimated as the measured flow velocity ­ (VR2, red arrow) due to
the Doppler angle (θ). ­VR2 is calculated by the following equation.
­VR2 = ­VR1 × cosθ
General Thoracic and Cardiovascular Surgery
(Fig. 6, ­VR1=the actual right flow velocity). The limitation
of the Doppler angle in the RPAB can cause the PSV to be
underestimated compared to the PSV in the LPAB [4]. These
reasons may still make the BPAB challenging operation and
need surgeon experiences. Therefore, we adopt the EDV to
PSV ratio as another indicator to achieve optimal tightness
in the BPAB since 2005.
The EDV to PSV ratio has been already used as one of
the indicators to assess non-hemodynamically significant
or restrictive PDA [5–9]. The EDV to PSV ratio shows a
significant correlation with ductal shunt volume measured
with magnetic resonance imaging [6]. The circulation after
BPAB in patients with ductal-dependent systemic circula-
tion is similar to the circulation in patients with PDA or
systemic to pulmonary artery shunt. The diastolic pulmo-
nary runoff is reflected in the EDV, which is absent in the
main pulmonary artery banding. Therefore, the EDV to PSV
ratio could indicate the tightness of the BPAB. The ratio
greater than 0.5 was defined and was an independent indica-
tor as a non-hemodynamically significant or restrictive PDA
[5–8]. Therefore, our target with the range of 0.4 to 0.6 may
be considered as a reasonable indicator. Furthermore, the
EDV to PSV ratio had no statistical difference throughout
the postoperative course, which may imply the ratio was not
affected by other factors although further investigations were
needed. In the present study, there was a lower incidence
(5.8%) of re-BPAB in the early postoperative period while
it has been reported as 16–20% [3, 11]. Therefore, the EDV
to PSV ratio can become a valuable indicator during the
BPAB. On the other hand, there are several considerations
when using the EDV to PSV ratio. First, during the measure-
ment of the PSV and the EDV, we should pay attention to
whether the direction of the ultrasonic beam passes through
the exact BPAB site which is very narrow. If the beam was
moved slightly at the distal site from the BPAB site, the PSV
and the EDV could be measured but could be underesti-
mated. Secondly, tight banding is difficult to assess tightness
because the banding site is extremely narrow. Therefore, we
initially evaluate the tightness using color Doppler mapping
which can provide the visualization of the tightness roughly.
Then, the PSV and the EDV to PSV ratio are measured to
perform the fine adjustment.
BPAB also needs to balance the right and left pulmonary
blood flow. However, it is challenging because of the lack of
information during BPAB to assess the flow distribution [4].
The PSV and the EDV are reflected in the gradient between
systemic arterial blood pressure and branch pulmonary
blood pressure at the peak systolic time and the end-diastolic
time, respectively, as described in patients with PDA [19]. If
both branch pulmonary blood pressure were almost equal,
the PSVs in the RPAB and LPAB were also almost equal as
long as the Doppler angle was 0°, which is difficult during
BPAB [4]. Meanwhile, The EDV to PSV ratio is not affected
by the Doppler angle, making it possible to assess the bal-
ance between the right pulmonary artery flow and the left
pulmonary artery flow in theory as shown by the following
equation. EDV×cosθ / PSV×cosθ= EDV / PSV (Fig 6). In
the present study, lung perfusion abnormality was detected
in only two patients who were at the beginning of the present
study because of a learning curve of the echocardiographic
measurement and the influence of compression of the BPAB
site by the pericardium or the chest close. In the late opera-
tive period, three patients required balloon angioplasty due
to perfusion abnormalities and decreased right upper lobe
perfusion. The serial EDV/PSV could show the balance
between the right pulmonary artery flow and the left pul-
monary artery flow in Tables 1 and 2. Therefore, the EDV
to PSV ratio can become a reliable indicator to maintain
balanced flow distribution to each lung.
There were some limitations in the present study. It
involved the retrospective, nonrandomized study and a
small number of patients. The difference between epicardial
echocardiography and transthoracic echocardiography might
affect the echocardiographic measurement. In the late post-
operative period, the aortopulmonary collateral artery could
affect the echocardiographic measurement. Lung perfusion
scintigraphy was used to quantify pulmonary blood flow to
each lung. The measurement of flow distribution to each
lung might be influenced by the cardiac position and the car-
diac size. Even if the pulmonary flow distribution is normal
and the cardiac position is normal, the right lung is slightly
higher than the left lung in the lung perfusion scintigraphy.
In conclusion, our clinical outcomes were satisfactory
with low early mortality, a low rate of re-BPAB and bal-
anced pulmonary flow distribution. Our study demonstrates
the EDV to PSV ratio can be a reliable indicator to assess
flow distribution to each lung. Furthermore, the EDV to PSV
ratio of 0.4–0.6 may be a valuable adjunct to SaO2, the PSV
and systemic blood pressure to achieve the balanced sys-
temic to pulmonary flow although further investigations are
needed.
Declarations 
Conflict of interest  Hiroshi Koshiyama declares that he has no conflict
of interest. Takamasa Takeuchi declares that he has no conflict of inter-
est. Junko Katagiri declares that she has no conflict of interest. Yusuke
Iwata declares that he has no conflict of interest.
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