OBJECTIVE : Large VSD presenting late with right to left shunt systemic PA pressures and unfavorable cardiac catheterization data are considered inoperable even in absence of clubbing and visible cyanosis. The rationale of treatment was based on the fact that if left untreated they progress to develop cyanosis and clubbing over next few years.

METHOD: In this prospective study PA banding & sildenafil was used in patients with criteria a. Systemic PA Pressures b. Basal right to left shunt (sat < 90 %) c. No clubbing d. PVR > 6 wood units on 100% oxygen + 40 ppmNO. Total of 15 patients had mean age - 8 yrs (range 2-14 yrs),weight of 25 kg (range 8-45 kg).
Results : PA Band was well tolerated in 14/15.The PA / Ao pressure in OR was 0.80 – 0.85.Sildenafil was started and Follow up was done with Echo + Cath upto 3yr .5/15 have undergone catheterization & PA /Ao pressure varied between 0.45 to 0.6. 4 patients (26.6%) have undergone Debanding & VSD Closure with smooth course and PA/Ao was 40-50 %.9 patients are 6 mo to 1yr post PA band & band gradient is 45 to 50 mm Hg.1patient did not tolerate the PA Band had to be debanded in OR. There was no mortality in the study.

Conclusion : PA Band followed by oral sildenafil therapy is safe and efficacious.This can possibly change the natural history of Early Eisenmenger VSD’s.