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Correspondence

Oral Sildenafil After Bidirectional Cavopulmonary Shunt

^a Department of Cardiac Surgery, Hammoud Hospital, Ghassan Hammoud St, PO Box 345 4433, Sidon, Lebanon
^b Department of Cardiac Surgery, Hotel-Dieu de France Hospital, PO Box 166 830, Naccache Blvd, Beirut, Lebanon

(Email: tonysoueide{at}hotmail.com; issam.rassi{at}gmail.com).

To the Editor:

We read with great interest the recent report by Nemoto and colleagues [1] 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 [2]. 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 [3].

In the case reported by Nemoto and colleagues [1], 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?

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1. Nemoto 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-e13.[Abstract/Free Full Text]
2. Miller OI, Tang SF, Keech A, Pigott NB, Beller E, Celermajer DS. Inhaled nitric oxide and prevention of pulmonary hypertension after congenital heart surgery: a randomised double-blind study Lancet 2000;356:1464-1469.[Medline]
3. Namachivayam P, Theilen U, Butt WW, Cooper SM, Penny DJ, Shekerdemian LS. Sildenafil prevents rebound pulmonary hypertension after withdrawal of nitric oxide in children Am J Respir Crit Care Med 2006;174:1042-1047.[Abstract/Free Full Text]

This article has been cited by other articles:

				S. Nemoto Reply Ann. Thorac. Surg., February 1, 2008; 85(2): 694 - 695. [Full Text] [PDF]

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