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Published on: February 27, 2017
Sildenafil's Early, Late Impact on Ventricular Septal Repair: Older Children Using the Double Patch
William M Novick1, Oleksandr S Golovenko2, Vasyl V Lazorhyshynets3
1University of Tennessee Health Science Center-Global Surgery Institute, Memphis, Tennessee; William Novick Global Cardiac Alliance, Memphis, Tennessee.
Insights
The double-flap valve (DFV) technique for ventricular septal defect (VSD) offers good long-term outcomes. Sildenafil use in VSD patients with pulmonary hypertension improved hemodynamics and postoperative recovery.
Area of Science:
- Cardiovascular Surgery
- Pediatric Cardiology
- Pulmonary Hypertension
Background:
- Delayed diagnosis of ventricular septal defect (VSD) in low- and middle-income countries leads to elevated pulmonary vascular resistance (PVR) and pulmonary arterial hypertension (PAH).
- The double-flap valve (DFV) VSD patch closure technique was introduced in 1996 to mitigate early postoperative risks.
- This report presents long-term results of the DFV technique.
Purpose of the Study:
- To evaluate the long-term efficacy and safety of the double-flap valve (DFV) technique for VSD closure.
- To assess the impact of sildenafil on preoperative hemodynamics and postoperative outcomes in VSD patients with PAH.
- To identify predictors of late severe PAH after DFV closure.
Main Methods:
- Retrospective single-institution study of 40 patients who underwent DFV between May 1996 and July 2015.
- Sildenafil was administered preoperatively and postoperatively to patients undergoing DFV from 2005 onwards.
- Analysis included preoperative catheterization data, operative, postoperative, hospital, and long-term follow-up data.
Main Results:
- Early and late mortality rates were low (2.5% and 2.6%, respectively).
- Sildenafil improved preoperative oxygen saturation, hemodynamics, and shortened postoperative ventilation time.
- At a median follow-up of 19.2 years, 97.3% survival was observed, with 18% having severe PAH. A baseline PVR-to-systemic vascular resistance ratio ≥ 0.8 predicted late severe PAH.
Conclusions:
- The DFV technique provides favorable long-term outcomes for VSD closure, with 60% achieving normal pulmonary artery pressures.
- Sildenafil administration enhances preoperative hemodynamics and postoperative management in VSD patients with elevated PVR and PAH.
- Children with VSD, elevated PVR, and PAH should be considered for surgical intervention.
Background:
Delayed diagnosis in children with a ventricular septal defect (VSD) is common in low- and middle-income countries. Consequently, these children present with elevated pulmonary vascular resistance (PVR) and pulmonary arterial hypertension (PAH). The study investigators introduced the double-flap valve VSD patch closure technique (DFV) in 1996 to reduce early postoperative risk. Long-term results are presented in this report.
Methods:
This was a retrospective single-institution study of patients who underwent DFV between May 1996 and July 2015. Beginning in 2005, all candidates for DFV received sildenafil preoperatively and postoperatively. Preoperative catheterization data and operative, postoperative, hospital, and follow-up data were analyzed.
Results:
A total of 40 patients underwent the DFV procedure. Patients' demographics were comparable between the sildenafil and nonsildenafil groups. One of 39 patients (2.6%) was lost to follow-up. Early mortality was 2.5% (1 of 40), and late mortality was 2.6% (1 of 38). Sildenafil improved preoperative oxygen saturation, improved preoperative hemodynamics, and shortened postoperative ventilation time. In both groups, abnormal hemodynamic values improved with a 100% oxygen challenge. The median age at late follow-up was 26.3 years (interquartile range [25%, 75%], 20.9, 29.9 years), and the median time since operation was 19.2 years (interquartile range, 11.4, 22.7 years). Current discharge survival was 97.3%. A total of 18% of patients had severe PAH in late follow-up. Multivariate analysis revealed only a baseline PVR-to-systemic vascular resistance ratio of 0.8 or greater as a significant predictor of late severe PAH.
Conclusions:
Long-term follow-up demonstrated that 60% of the patients will achieve normal or nearly normal pulmonary artery pressures. Furthermore, the study demonstrated that sildenafil improves preoperative hemodynamics and postoperative management. Children with VSD, elevated PVR, and PAH should not be denied operation.
