Pulmonary vasodilator therapy and early postoperative outcome after modified Fontan operation

Abstract

Although mortality is low after the modified Fontan procedure, there is a significant percentage of patients with prolonged postoperative recovery. The objective of this study is to evaluate the usefulness of postoperative administration of oral sildenafil and inhaled nitric oxide on early postoperative outcome. A prospective interventional and comparison study with a historical cohort was conducted. Between January, 2010 and March, 2013, 16 patients received oral sildenafil during immediate modified Fontan postoperative period. Inhaled nitric oxide was also administered if the patient was kept intubated 12 hours after surgery. Early postoperative outcome was compared with a historical cohort of 32 patients on whom the modified Fontan procedure was performed between March, 2000 and December, 2009. Postoperative administration of sildenafil and nitric oxide had no influence on early postoperative outcome after the modified Fontan procedure in terms of duration of pleural effusions, mechanical ventilation time, length of stay in the ICU, and length of hospital stay.

The effect of sildenafil on pleural and peritoneal effusions after the TCPC operation

“…Whether earlier extubation was due to the use of sildenafil or the awareness of the benefits of early extubation remains a question. Subsequent studies have not been able to reproduce these outcomes 6. In our study, the mean intubation time in the sildenafil group(19.6 ± 31.9 h) and the control group (19.0 ± 27.0 h) were compared with the control group of Giordano's study.…”

“…5 In contrast, a study by Mendoza et al found that sildenafil and inhaled nitric oxide did not influence the duration of pleural effusion, mechanical ventilation, or the lengths of PICU or hospital stay. 6 Sildenafil reduced the pulmonary vascular resistance, but it also increased systemic vasodilatation, which may increase the need for post-operative fluid resuscitation.…”

“…4 Therefore, in 2006, our institution started the administration of sildenafil after the TCPC operation for occasional patients and usually later than 24 hours after the operation, and since 2009, the majority of the patients received their first dose of sildenafil pre-operatively in the morning of the operation.However, the benefits of sildenafil have been controversial in the two recent retrospective Fontan series. 5,6 Our aim in this study was to analyze the effect of prophylactic sildenafil on pleural and peritoneal effusions during the first post-operative day (POD) after the TCPC surgery. We hypothesized that the…”

“…However, the benefits of sildenafil have been controversial in the two recent retrospective Fontan series. 5,6 Our aim in this study was to analyze the effect of prophylactic sildenafil on pleural and peritoneal effusions during the first post-operative day (POD) after the TCPC surgery. We hypothesized that the…”

Pulmonary vasodilator therapy as treatment for patients with a Fontan circulation: the Emperor’s new clothes?

“…First, concerning inclusion criteria; two of the included studies are not RCTs (one retrospective design and one prospective design with a historical cohort control group) and thus in fact do not fulfill the authors’ inclusion criteria of RCT-only studies. 3 , 4 Without these two studies there is only one RCT reporting on mean pulmonary artery pressure (mPAP) 5 and only RCT data from one medical center on mortality, 5 , 6 making a meta-analysis on hemodynamics and mortality a futile attempt. As a consequence, no meaningful conclusions can be drawn considering mPAP and mortality.…”