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Correspondence

Reply

Department of Thoracic and Cardiovascular Surgery, Osaka Medical College, 2-7 Daigaku-machi, Takatsuki, Osaka 569-8686, Japan

(Email: snemoto{at}poh.osaka-med.ac.jp).

To the Editor:

We 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. In fact, both inhaled nitrous oxide and sildenafil ameliorated impaired pulmonary circulation with improvement of oxygen saturation and the transpulmonary pressure gradient in our reported case [2]. The patient showed a favorable response to sildenafil for treatment of impaired pulmonary circulation, even after bi-directional cavopulmonary shunt and corrective surgery for a large left-to-right shunt [4].

Although Drs Soueide and Rassi [1] agreed with the salvatory effect of oral sildenafil in this case, they brought up the indication of the last (ie, the third) operation, with discussion of an alternative surgical option and the future feasibility of Fontan completion. We would like to add the following comments to this discussion.

The patient had already undergone a bidirectional cavopulmonary shunt with repeat pulmonary artery banding and reconstruction of the pulmonary artery as the second surgery, with an uneventful postoperative course. However, the repeat pulmonary banding resulted in pulmonary hypertension in the left pulmonary artery due to excess forward pulmonary blood flow. Therefore, the indication of a standard bi-directional cavopulmonary shunt after an initial palliation, as mentioned by Drs Soueide and Rassi [1], does not apply to the third operation in this case [2], especially when pulmonary hypertension remains after pulmonary artery banding [6]. The goal of the third surgery was to normalize the increased pressure in the left pulmonary artery by reducing the excess forward pulmonary blood flow prior to a future Fontan completion. Because of the two failed attempts at pulmonary artery banding, we performed transection of the main pulmonary artery concomitant with repeated pulmonary artery reconstruction, with the goal of redirection of the blood flow from the cavopulmonary shunt into both pulmonary arteries, rather than a third attempt at pulmonary artery banding. Postoperative radionuclide pulmonary perfusion scanning showed equivalent uptake in both lungs with a reasonable pulmonary artery pressure at discharge from the intensive care unit. Therefore, we believe that the indication of the third surgery was practicable. Alternatively, we might have performed transection of the main pulmonary artery with or without Damus-Kaye-Stansel anastomosis with a right ventricle-to-pulmonary artery conduit, as a second surgery prior to a bi-directional cavopulmonary shunt, to better regulate pulmonary arterial flow and pressure. A follow-up cardiac catheterization is mandatory to evaluate the feasibility of a Fontan completion on the basis of pulmonary circulation and cardiac function in this case. We hope that new drugs for pulmonary hypertension, such as sildenafil and bosentan (an endothelin dual receptor blocker) will extend the boundary of the indication for a bi-directional cavopulmonary shunt or a Fontan completion.

	References

Top References

 

1. Soueide T, Rassi I. Oral sildenafil after bidirectional cavopulmonary shunt (letter) Ann Thorac Surg 2008;85:693-694.[Free Full Text]
2. Nemoto S, Umehara E, Ikeda T, Itonaga T, Komeda M. Oral sildenafil ameliorates impaired pulmonary circulation early after bidiractional cavopulmonary shunt Ann Thorac Surg 2007;83:e11-e13.[Abstract/Free Full Text]
3. Miller OI, Tang SF, Keech A, Pigott NB, Beller E, Celermajor DS. Inhaled nitric oxide and prevention of pulmonary hypertension after congenital heart surgery: a randomised double-blind study Lancet 2000;356:1464-1469.[Medline]
4. Stocker C, Penny DJ, Brizard CP, Cochrane AD, Soto R, Shekerdemian LS. Intravenous sildenafil and inhaled nitric oxide: randomized trial in infants after cardiac surgery Intensive Care Med 2003;29:1996-2003.[Medline]
5. Atz AM, Lefler AK, Fairbrother DL, Uber WE, Bradley SM. Sildenafil augments the effects of inhaled nitric oxide for postoperative pulmonary hypertensive crisis J Thorac Cardiovasc Surg 2002;124:628-629.[Free Full Text]
6. Chowdhury UK, Airan B, Kothari SS, et al. Surgical outcome of staged univentricular-type repairs for patients with univentricular physiology and pulmonary hypertension Indian Heart J 2004;56:320-327.[Medline]

This Article Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Shintaro Nemoto Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Nemoto, S. Search for Related Content PubMed Articles by Nemoto, S. Related Collections Related Article