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• W2083488892 abstract "We read with great interest the recent report by Nemoto and colleagues [1Nemoto S. Umehara E. Ikeda T. Itonaga T. Komeda M. Oral sildenafil ameliorates impaired pulmonary circulation early after bidirectional cavopulmonary shunt.Ann Thorac Surg. 2007; 83: e11-e13Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar] in which they described the effect of sildenafil on impaired pulmonary circulation early after bi-directional cavopulmonary shunt. Impaired pulmonary circulation remains a major cause of mortality and morbidity after surgery for congenital heart disease. Pulmonary hypertension in patients with left-to-right shunt lesions is related to endothelial dysfunction that is exacerbated by cardiopulmonary bypass; as a result, nitric oxide, a vasodilator derived from the pulmonary endothelium, will be deficient leading to pulmonary vasoconstriction and consequential pulmonary hypertension. Inhaled nitric oxide counteracts pulmonary vasoconstriction by a direct action on pulmonary vascular smooth muscle through the increase of cyclic guanosine monophosphate (cGMP); it is rapidly degraded by phosphodiesterases in the hemoglobin [2Miller O.I. Tang S.F. Keech A. Pigott N.B. Beller E. Celermajer D.S. Inhaled nitric oxide and prevention of pulmonary hypertension after congenital heart surgery: a randomised double-blind study.Lancet. 2000; 356: 1464-1469Abstract Full Text Full Text PDF PubMed Scopus (190) Google Scholar]. The rebound effect after discontinuation of nitric oxide is a known complication that may be explained by the depletion of cGMP. Sildenafil, a phosphodiesterase inhibitor plays a pivotal role in weaning patients from nitric oxide by preventing the rebound effect after withdrawal of the gas [3Namachivayam P. Theilen U. Butt W.W. Cooper S.M. Penny D.J. Shekerdemian L.S. Sildenafil prevents rebound pulmonary hypertension after withdrawal of nitric oxide in children.Am J Respir Crit Care Med. 2006; 174: 1042-1047Crossref PubMed Scopus (147) Google Scholar].In the case reported by Nemoto and colleagues [1Nemoto S. Umehara E. Ikeda T. Itonaga T. Komeda M. Oral sildenafil ameliorates impaired pulmonary circulation early after bidirectional cavopulmonary shunt.Ann Thorac Surg. 2007; 83: e11-e13Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar], sildenafil has certainly improved the impaired pulmonary circulation as evidenced by the improvement of oxygen saturation and the transpulmonary gradient. However, failure of a bi-directional cavopulmonary shunt would usually prompt us to do a root cause analysis, such as reconsidering the adequacy of its indications, or sometimes consider an alternative surgical approach. Despite the salvatory effect of sildenafil in this patient, do you think that a Fontan-like procedure would be feasible in the future? We read with great interest the recent report by Nemoto and colleagues [1Nemoto S. Umehara E. Ikeda T. Itonaga T. Komeda M. Oral sildenafil ameliorates impaired pulmonary circulation early after bidirectional cavopulmonary shunt.Ann Thorac Surg. 2007; 83: e11-e13Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar] in which they described the effect of sildenafil on impaired pulmonary circulation early after bi-directional cavopulmonary shunt. Impaired pulmonary circulation remains a major cause of mortality and morbidity after surgery for congenital heart disease. Pulmonary hypertension in patients with left-to-right shunt lesions is related to endothelial dysfunction that is exacerbated by cardiopulmonary bypass; as a result, nitric oxide, a vasodilator derived from the pulmonary endothelium, will be deficient leading to pulmonary vasoconstriction and consequential pulmonary hypertension. Inhaled nitric oxide counteracts pulmonary vasoconstriction by a direct action on pulmonary vascular smooth muscle through the increase of cyclic guanosine monophosphate (cGMP); it is rapidly degraded by phosphodiesterases in the hemoglobin [2Miller O.I. Tang S.F. Keech A. Pigott N.B. Beller E. Celermajer D.S. Inhaled nitric oxide and prevention of pulmonary hypertension after congenital heart surgery: a randomised double-blind study.Lancet. 2000; 356: 1464-1469Abstract Full Text Full Text PDF PubMed Scopus (190) Google Scholar]. The rebound effect after discontinuation of nitric oxide is a known complication that may be explained by the depletion of cGMP. Sildenafil, a phosphodiesterase inhibitor plays a pivotal role in weaning patients from nitric oxide by preventing the rebound effect after withdrawal of the gas [3Namachivayam P. Theilen U. Butt W.W. Cooper S.M. Penny D.J. Shekerdemian L.S. Sildenafil prevents rebound pulmonary hypertension after withdrawal of nitric oxide in children.Am J Respir Crit Care Med. 2006; 174: 1042-1047Crossref PubMed Scopus (147) Google Scholar]. In the case reported by Nemoto and colleagues [1Nemoto S. Umehara E. Ikeda T. Itonaga T. Komeda M. Oral sildenafil ameliorates impaired pulmonary circulation early after bidirectional cavopulmonary shunt.Ann Thorac Surg. 2007; 83: e11-e13Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar], sildenafil has certainly improved the impaired pulmonary circulation as evidenced by the improvement of oxygen saturation and the transpulmonary gradient. However, failure of a bi-directional cavopulmonary shunt would usually prompt us to do a root cause analysis, such as reconsidering the adequacy of its indications, or sometimes consider an alternative surgical approach. Despite the salvatory effect of sildenafil in this patient, do you think that a Fontan-like procedure would be feasible in the future? ReplyThe Annals of Thoracic SurgeryVol. 85Issue 2PreviewWe appreciate the thoughtful comments of Drs Soueide and Rassi [1] regarding our article [2]. As pointed out [1], it is well recognized that cyclic guanosine monophosphate (cGMP) plays a clinically important role in maintaining pulmonary vascular tone (ie, pulmonary vasodilation, even immediately after cardiac surgery). Along with cGMP production therapy with inhaled nitric oxide for pulmonary hypertension [3], sildenafil has recently been recognized as an effective treatment option for various types of pulmonary hypertension and impaired pulmonary circulation [4, 5] by inhibiting degradation of cGMP. Full-Text PDF" @default.
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• W2083488892 title "Oral Sildenafil After Bidirectional Cavopulmonary Shunt" @default.
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