Do preoperative haemodynamic data and reactivity test predict the postoperative reversibility of pulmonary arterial hypertension in patients with large ventricular septal defect and borderline operability?

Sildenafil's Early, Late Impact on Ventricular Septal Repair: Older Children Using the Double Patch

BACKGROUND

Delayed diagnosis in children with a ventricular septal defect (VSD) is common in developing countries. Consequently, they present with elevated pulmonary vascular resistance (PVR) and pulmonary arterial hypertension (PAH). We introduced the double-flap valve VSD patch closure technique (DFV) in 1996 to reduce early post- operative risk. Long-term results are presented herein.

METHODS

This is a retrospective single-institution study on DFV patients performed between 5/1996 and 7/2015. Beginning in 2005 all candidates for DFV received sildenafil pre-and post-operatively. Pre-operative catheterization data, operative, post-operative, hospital and follow-up data were analyzed.

RESULTS

Forty patients received the DFV surgery. Patient demographics were comparable between sildenafil and non-sildenafil groups. Lost to follow up 1/39 (2.6%). Early mortality: 1/40 (2.5%), late mortality: 1/38 (2.6%). Sildenafil improved pre-op saturation, improved pre-operative hemodynamics as well as shortened prost-operative ventilation time. In both groups abnormal hemodynamic parameters improved with 100% oxygen challenge. The median age at late follow-up was 26.3 years (20.9; 29.9[25%; 75% Intra-quartile range]) and the median time since operation was 19.2 years (11.4; 22.7). Current discharge survival was 97.3%. Patients with severe PAH in late follow-up was 18%. Multi-variate analysis revealed only baseline PVR/SVR ≥ 0.8 as a significant predictor of late severe PAH.

CONCLUSIONS

Our long-term follow-up demonstrates that 60% of the patients will achieve normal or near normal PA pressures. Furthermore, we have demonstrated that sildenafil improves. pre-operative hemodynamics and post-operate management. Children with VSD, elevated PVR and PAH should not be denied operation.

Preventing disease progression in Eisenmenger syndrome

Introduction: Eisenmenger syndrome describes a condition in which a congenital heart defect has caused severe pulmonary vascular disease, resulting in reversed (right-left) or bidirectional shunting and chronic cyanosis.Areas covered: In this paper, the progression of congenital heart defects to Eisenmenger syndrome, including early screening, diagnosis and operability are covered. The mechanisms of disease progression in Eisenmenger syndrome and management strategies to combat this, including the role of pulmonary arterial hypertension therapies, are also discussed.Expert opinion/commentary: Patients with congenital heart disease (CHD) are at increased risk of developing pulmonary arterial hypertension with Eisenmenger syndrome being its extreme manifestation. All CHD patients should be regularly assessed for pulmonary hypertension. Once Eisenmenger syndrome develops, shunt closure should be avoided. The clinical manifestations of Eisenmenger syndrome are driven by the systemic effects of the pulmonary hypertension, congenital defect and long-standing cyanosis. Expert care is essential for avoiding pitfalls and preventing disease progression in this severe chronic condition, which is associated with significant morbidity and mortality. Pulmonary arterial hypertension therapies have been used alongside supportive care to improve the quality of life, exercise tolerance and the outcome of these patients, although the optimal timing for their introduction and escalation remains uncertain.

Cruciate Fenestration in Ventricular Septal Defect Patch for High-Risk Patients With High Pulmonary Vascular Resistance

Late presentation of patients with large ventricular septal defect (VSD) and elevated pulmonary vascular resistance (PVR) is not uncommon in developing countries. Surgical VSD closure in these patients carries risks of persistent pulmonary hypertension, right ventricular failure, and mortality. Several techniques for creation of valved patches or fenestrated patches have been developed to address these issues. We have successfully used a simple and easily reproducible technique in which a cruciate fenestration is created in the patch used for VSD closure.