Effect of preoperative oral sildenafil on severe pulmonary artery hypertension in patients undergoing mitral valve replacement

Abstract

Aim:Long standing mitral valve disease is usually associated with severe pulmonary hypertension. Perioperative pulmonary hypertension is a risk factor for right ventricular (RV) failure and a cause for morbidity and mortality in patients undergoing mitral valve replacement. Phosphodiesterase 5 inhibitor-sildenafil citrate is widely used to treat primary pulmonary hypertension. There is a lack of evidence of effects of oral sildenafil on secondary pulmonary hypertension due to mitral valve disease. The study aims to assess the effectiveness of preoperative oral sildenafil on severe pulmonary hypertension and incidence of RV failure in patients undergoing mitral valve replacement surgery.Materials and Methods:A total of 40 patients scheduled for mitral valve replacement with severe pulmonary hypertension (RV systolic pressure (RVSP) ≥60 mmHg) on preoperative transthoracic echo were randomly treated with oral sildenafil 25 mg (N = 20) or placebo (N = 20) eight hourly for 24 h before surgery. Hemodynamic variables were measured 20 min after insertion of pulmonary artery catheter (PAC) under anesthesia (T1), 20 min at weaning from cardiopulmonary bypass (CPB) (T2) and after 1,2, and 6 h (T3, T4, T5, respectively) during the postoperative period.Results:Systolic and mean pulmonary artery pressure (MPAP) and pulmonary vascular resistance index (PVRI) were significantly lower (P < 0.0001) in sildenafil group at all times. Ventilation time and postoperative recovery room stay were significantly lower (P < 0.001) in sildenafil group.Conclusion:Sildenafil produces significant pulmonary vasodilatory effect as compared with placebo in mitral valve replacement patients with severe pulmonary hypertension. It also reduces ventilation time and intensive care unit (ICU) stay time as compared with placebo. It is concluded that sildenafil is effective in reducing pulmonary hypertension when administered preoperatively in patients with severe pulmonary hypertension undergoing mitral valve replacement surgery.

Pre-Operative Sildenafil for Patients With Pulmonary Hypertension Undergoing Mitral Valve Surgery: A Systematic Review and Meta-Analysis

“…The following is the description of the included studies. Table 1 summarizes the characteristics and details of the included studies [20-22]. All studies were conducted in different tertiary hospitals.…”

“…All studies were conducted in different tertiary hospitals. In the study by Ayyad et al [21], the mean age was 32 ± 10.4 years with more women in the placebo group; in the study by Gandhi et al [22], the mean age was 38.79 ± 8.62 years with 50% men; and in the study by Shim et al [20], the mean age was 50 ± 11.5 years with 39% men. Almost all the patients in the three studies underwent elective mitral valve replacement due to either mitral stenosis or mitral regurgitation.…”

“…Both Shim et al [20] and Gandhi et al [22] reported changes in pulmonary and systemic vascular resistance. It was shown that pulmonary vascular resistance (Fig.…”

“…They observed a similar trend of lowering the intra-operative systolic pulmonary artery pressure (sPAP) after immediate pre-operative administration of sildenafil without affecting the other hemodynamic parameters. Administration of sildenafil three times a day 24 h prior to the schedule of surgery also showed significant lowering of the intra-operative pulmonary pressures and decrease in inotrope requirement post-operatively among patients with severe pre-operative PH undergoing mitral valve surgery [22]. These three small trials have shown that pre-operative administration of sildenafil has a significant effect on the intra-operative parameters among these patients.…”

Postoperative Right Ventricular Failure in Cardiac Surgery

“…Gandhi et al showed in a clinical trial with 40 patients that suffered from severe PH that were scheduled for mitral valve replacement that sildenafil administered before surgery reduced PH and the need for mechanical ventilation compared to placebo [ 53 ].…”