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

Abstract

BackgroundPulmonary hypertension is a usual complication of long-standing mitral valve disease. Perioperative pulmonary hypertension is a risk factor for right ventricular failure and is an important cause of morbidity and mortality in patients with pulmonary hypertension undergoing mitral valve surgery. Phosphodiesterase-5 inhibitors particularly sildenafil citrate have proven clinical benefit for pulmonary arterial hypertension but have shown discordant results in group 2 pulmonary hypertension patients. We sought to determine the effect of pre-operative sildenafil on the intra-operative hemodynamic parameters of these patients.MethodsStudies were included if they satisfied the following criteria: 1) Randomized controlled trials; 2) Adult patients with pulmonary hypertension scheduled for elective mitral valve surgery; and 3) Reported data on changes in pre-, intra-, and post-operative hemodynamic parameters. Using PUBMED, Clinical Key, Science Direct, and Cochrane databases, a search for eligible studies was conducted from September 1 to December 31, 2018. The quality of each study was evaluated using the Cochrane Risk of Bias Tool. The primary outcome of interest is on the effect of pre-operative sildenafil on the improvement of intra-operative hemodynamic parameters such as systolic pulmonary artery pressure (sPAP), mean pulmonary arterial pressure, mean arterial pressure, pulmonary and systemic vascular resistances. We also investigated its effect on the post-operative mortality, length of cardiopulmonary bypass time, ventilation time, and inotrope support requirement. Review Manager 5.3 was utilized to perform analysis of random effects for continuous outcomes.ResultsWe identified three studies involving 153 patients with pulmonary hypertension undergoing mitral valve surgery, showing that among those who received pre-operative sildenafil there is a significant decrease in intra-operative systolic pulmonary arterial pressure (mean difference -11.19 (95% confidence interval (CI), -20.23 to -2.15), P < 0.05) and post-operative sPAP (mean difference -13.67 (95% CI, - 19.56 to - 7.78), P < 0.05) without significantly affecting the mean arterial pressure (mean difference 1.94 (95% CI, -5.49 to 9.37), P < 0.05). The systemic and pulmonary vascular resistances were not affected as well.ConclusionsAdministration of pre-operative sildenafil to patients with pulmonary hypertension undergoing mitral valve surgery decreases intra-operative and post-operative systolic pulmonary arterial pressure without significantly affecting other systemic hemodynamic parameters.

Efficacy of Beraprost Sodium Combined with Sildenafil and Its Effects on Vascular Endothelial Function and Inflammation in Patients Experiencing Left Heart Failure Complicated with Pulmonary Arterial Hypertension

“…Left heart failure, an impairment of cardiac function caused by multiple underlying heart diseases, can give rise to changes in myocardial structure and function [ 8 ], and it will progress until left heart pumping dysfunction, decreased filling capacity, and systolic dysfunction occur [ 9 ]. As the course is extended, left heart failure can induce water-sodium retention, congestion in the pulmonary and systemic circulation, elevated left ventricular preload and afterload, and even secondary pulmonary arterial hypertension [ 10 ].…”

Effectiveness of Sildenafil in Pulmonary Hypertension Secondary to Valvular Heart Disease: A Systematic Review and Meta-Analysis

“…Several systematic and meta-analysis studies have been conducted to determine the effectiveness of sildenafil in various populations [17][18][19][20]. A recent review only evaluated the effects of preoperative sildenafil in PH patients undergoing mitral valve surgery [18] and did not compare the effects of sildenafil when given postoperatively and long term for PH secondary to VHD.…”

Role of per-operative milrinone on pulmonary hypertension having mitral valve replacement.

“…1 The most common cause of pulmonary hypertension worldwide is left heart disease 2 amongst which valvular heart disease is the leading cause of secondary pulmonary hypertension. 3 Patients with symptomatic mitral valve disease are severely affected by pulmonary hypertension and upto 65% of patients with symptomatic mitral stenosis 4,5 have increased risk of morbidity and mortality during mitral valve replacement (MVR). 6 Mitral stenosis results in increase in left atrial pressures causing reversible increase in pulmonary arterial pressures 7 Immediately after MVR, pulmonary arterial pressure does not usually regress completely and persist in about 75% of patients having pre-operation severe pulmonary hypertension 8 Milrinone is a phosphodiesterase inhibitor which is commonly used in such patients during weaning from cardiopulmonary bypass, to reduce the pulmonary vascular resistance 9 Milrinone reduces biventricular filling pressures and afterload by systemic and pulmonary vasodilation.…”