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Published on: May 11, 2015
Perioperative sildenafil therapy for pulmonary hypertension in infants undergoing congenital cardiac defect closure
Ashraf A H El Midany1, Ezzeldin A Mostafa, Sherif Azab
1Department of Cardiovascular & Thoracic Surgery, Ain Shams University, Cairo, Egypt.
Insights
Sildenafil effectively reduces pulmonary artery pressure in infants with ventricular septal defects. Early administration before surgery offers no significant advantage over postoperative use for improving outcomes.
Area of Science:
- Pediatric Cardiology
- Cardiovascular Surgery
- Pharmacology
Background:
- Pulmonary hypertension in pediatric ventricular septal defect (VSD) significantly impacts perioperative outcomes.
- Sildenafil, an oral pulmonary vasodilator, is well-tolerated with minimal drug interactions.
Purpose of the Study:
- To evaluate the impact of oral sildenafil timing on pulmonary artery pressure and patient outcomes in infants with VSD.
- Comparison of pre- and postoperative sildenafil initiation versus postoperative-only initiation.
Main Methods:
- 101 infants with large VSDs and moderate-to-severe pulmonary hypertension were randomized.
- Sildenafil group (n=51) received medication 2 weeks pre-surgery and post-surgery.
- Control group (n=50) received sildenafil only post-surgery, with gradual dose titration up to 2 mg/kg.
Main Results:
- Mean pulmonary artery pressure significantly decreased in both groups post-treatment (P < 0.0001).
- Intensive care unit stay was significantly shorter in the sildenafil group.
- No adverse effects were reported; no significant differences in ventilation duration or hospital stay.
Conclusions:
- Sildenafil is a cost-effective, orally available option for secondary pulmonary hypertension in VSD, particularly in resource-limited settings.
- Early initiation of sildenafil before VSD surgery does not provide additional benefits for postoperative pulmonary hypertension or patient outcomes.
Objectives:
Pulmonary hypertension in paediatric patients with ventricular septal defect remains one of the most important determinants of perioperative morbidity and mortality. Sildenafil is an oral, well-tolerated pulmonary vasodilator with few drug interactions. We studied the effect of oral sildenafil, when given before and after surgical closure compared with starting it postoperatively, on the pulmonary artery pressure and patients' outcome.
Methods:
We enrolled 101 infants with large ventricular septal defects who had moderate-to-severe pulmonary hypertension scheduled for surgical closure. They were randomly assigned to the sildenafil group (n = 51, mean age 10 months and mean weight 6.5 kg), in which oral sildenafil was started 2 weeks before surgery to be continued postoperatively, and to the control group (n = 50, mean age 11 months and mean weight 7.3 kg), in which sildenafil was started only postoperatively. It was started at 0.5 mg/kg and increased gradually to a maximum dose of 2 mg/kg in both groups.
Results:
Overall hospital mortality was 4.9%. Mean pulmonary artery pressure decreased significantly at all time points of recording in both groups (P < 0.0001). In the sildenafil group, it decreased preoperatively after sildenafil administration from 75.4 to 59.4 mmHg and postoperatively from 50.4 mmHg immediate post-cardiopulmonary bypass to reach 44.2 mmHg before discharge. In the control group, it decreased from 74.6 mmHg to 51 mmHg immediate post-cardiopulmonary bypass to reach 42.7 mmHg before discharge. No adverse effects have been recorded. Although there was no difference in the duration of mechanical ventilation and hospital stay between the two groups, intensive care unit stay was significantly shorter in the sildenafil group. Dobutamine doses were significantly higher in the sildenafil group; however, milrinone and epinephrine have been used more significantly in the control group.
Conclusions:
The low cost, the oral availability and the good tolerability of sildenafil make it a suitable and simple alternative therapy for secondary pulmonary hypertension including persistent postoperative pulmonary hypertension associated with ventricular septal defect in resource limited places. However, starting sildenafil early before surgery does not add a great benefit in terms of improving postoperative pulmonary hypertension or patients' outcome.
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