INTRA-OPERATIVE AND POSTOPERATIVE OUTCOMES AND REQUIREMENT OF POSTOPERATIVE SILDENAFIL THERAPY IN PATIENTS WITH MITRAL VALVE DISEASE WITH SEVERE PULMONARY HYPERTENSION ON PREOPERATIVE ORAL SILDENAFIL THERAPY- REVIEW OF LITERATURE
Main Article Content
Keywords
Sildenafil, Pulmonary hypertension, Mitral valve disease, Cardiothoracic surgery, Perioperative management, Pulmonary vasodilators
Abstract
Severe pulmonary hypertension has remained one of the dominant factors of perioperative morbidity and mortality among patients undergoing mitral valve surgery. The use of preoperative oral sildenafil therapy has been of growing interest as a method of maximising the pulmonary vascular hemodynamics and right ventricular functioning before surgery. Despite the fact that mitral valve repair or replacement may usually result in a decrease in the pulmonary pressures as a result of reducing left-sided cardiac obstruction, it is observed that a number of patients still record an increased pulmonary vascular resistance during the postoperative period than pre-operative times. These malfunctions lead to instability in the operating room, difficulty in weaning from cardiopulmonary bypass and difficulty in the postoperative recovery. Sildenafil, as a selective pulmonary vasodilator, can decrease the pulmonary artery pressures, improve the loading status of the right ventricle and improve the overall stability during the perioperative period. Nonetheless, its impact in the intra-operative period and the postoperative period is different with respect to the severity of the underlying disease, ventricular functioning, and postoperative hemodynamic reaction. Moreover, there are unanswered questions on which patients would be helped by the further use of sildenafil post-surgery and which ones can be harmed due to unwarranted exposure. This review summarises the modern evidence that assesses the effect of the preoperative administration of sildenafil on intra-operative and postoperative hemodynamic conditions, postoperative outcomes, and the clinical reasons for the continuity of the therapy after surgery. Further insight into these correlations can assist in refining the approaches of perioperative management and identify the patients who can benefit the most by receiving a customised pulmonary vasodilator treatment.
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2. Ameri, A., Giordanino, E., Favaloro, L., Renedo, M., della Cella Figueredo, R., Favaloro, R., ... & Bertolotti, A. (2022). Hemodynamic Implications of Sildenafil in Candidates for Heart Transplantation with Group 2 Pulmonary Hypertension: A Single Latin-American Center Registry. The Journal of Heart and Lung Transplantation, 41(4), S442.
3. Barnes, H., Brown, Z., Burns, A., & Williams, T. (2019). Phosphodiesterase 5 inhibitors for pulmonary hypertension. Cochrane Database of Systematic Reviews, (1).
4. Bermejo, J., González‐Mansilla, A., Mombiela, T., Fernández, A. I., Martínez‐Legazpi, P., Yotti, R., ... & SIOVAC (“Sildenafil for Improving Outcomes after VAlvular Correction”) Investigators. (2021). Persistent pulmonary hypertension in corrected valvular heart disease: hemodynamic insights and long‐term survival. Journal of the American Heart Association, 10(2), e019949.
5. Bermejo, J., Yotti, R., García-Orta, R., Sánchez-Fernández, P. L., Castaño, M., Segovia-Cubero, J., ... & Fernández-Avilés, F. (2018). Sildenafil for improving outcomes in patients with corrected valvular heart disease and persistent pulmonary hypertension: a multicenter, double-blind, randomized clinical trial. European Heart Journal, 39(15), 1255-1264.
6. Briongos Figuero, S., Moya Mur, J. L., García-Lledó, A., Centella, T., Salido, L., Aceña Navarro, Á., ... & Zamorano, J. L. (2016). Predictors of persistent pulmonary hypertension after mitral valve replacement. Heart and vessels, 31(7), 1091-1099.
7. Cajigas, H. R., Kaptzan, T., Lewis, B., El‐Sabbagh, A., Al‐Hijji, M., Eleid, M., ... & Guerrero, M. (2022). The impact of pulmonary hypertension on outcomes of transcatheter mitral valve replacement in mitral annular calcification. Catheterization and Cardiovascular Interventions, 99(5), 1647-1658.
8. CHEEMA, S. A., MIKRANI, B., JUMADIN, A., MAHMOOD, M. M., YASIR, M., & NIAZI, A. K. (2025). Optimal Duration of Oral Sildenafil for Perioperative Management of Severe Pulmonary Hypertension in Mitral Valve Replacement. Pakistan Journal of Medical & Health Sciences Vol, 19, 5.
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12. David, N., Lakha, S., Walsh, S., Fried, E., & DeMaria Jr, S. (2024). Novel inhaled pulmonary vasodilators in adult cardiac surgery: a scoping review. Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 71(8), 1154-1162.
13. Desai, K., Di Lorenzo, M., Zuckerman, W. A., Emeruwa, E., & Krishnan, U. S. (2023). Safety and efficacy of sildenafil for group 2 pulmonary hypertension in left heart failure. Children, 10(2), 270.
14. Díaz-Gómez, J. L., Ripoll, J. G., Mira-Avendano, I., Moss, J. E., Divertie, G. D., Frank, R. D., & Burger, C. D. (2018). Multidisciplinary perioperative management of pulmonary arterial hypertension in patients undergoing noncardiac surgery. South Med J, 111(1), 64-73.
15. Diaz-Rodriguez, N., Nyhan, S. M., Kolb, T. M., & Steppan, J. (2022). How we would treat our own pulmonary hypertension if we needed to undergo cardiac surgery. Journal of cardiothoracic and vascular anesthesia, 36(6), 1540-1548.
16. Dumitrescu, D., Koster, A., Erdoes, G., & Denault, A. Y. (2022). Perioperative Management of Pulmonary Hypertension During Cardiac Surgery: A Call for Interdisciplinary Networking. Journal of Cardiothoracic and Vascular Anesthesia, 36(6), 1549-1551.
17. Haddad, F., Kudelko, K., Mercier, O., Vrtovec, B., Zamanian, R. T., & de Jesus Perez, V. (2011). Pulmonary hypertension associated with left heart disease: characteristics, emerging concepts, and treatment strategies. Progress in cardiovascular diseases, 54(2), 154-167.
18. Halvorsen, S., Mehilli, J., Cassese, S., Hall, T. S., Abdelhamid, M., Barbato, E., ... & Zacharowski, K. (2022). 2022 ESC Guidelines on cardiovascular assessment and management of patients undergoing non-cardiac surgery: Developed by the task force for cardiovascular assessment and management of patients undergoing non-cardiac surgery of the European Society of Cardiology (ESC) Endorsed by the European Society of Anaesthesiology and Intensive Care (ESAIC). European heart journal, 43(39), 3826-3924.
19. Hu, X., Li, X., Boggett, S., Yang, Y., Chun-Ting, W., Anstey, J., ... & Royse, C. (2020). Routine intraoperative inhaled milrinone and iloprost reduces inotrope use in patients undergoing cardiac surgery: a retrospective cohort pilot study. Anesthesia & Analgesia, 131(2), 527-536.
20. Humbert, M., Kovacs, G., Hoeper, M. M., Badagliacca, R., Berger, R. M., Brida, M., ... & Rosenkranz, S. (2022). 2022 ESC/ERS Guidelines for the diagnosis and treatment of pulmonary hypertension: Developed by the task force for the diagnosis and treatment of pulmonary hypertension of the European Society of Cardiology (ESC) and the European Respiratory Society (ERS). Endorsed by the International Society for Heart and Lung Transplantation (ISHLT) and the European Reference Network on rare respiratory diseases (ERN-LUNG). European heart journal, 43(38), 3618-3731.
21. Ibrahim, I. M., Dokhan, A. L., Elsebaey, R. S., & Abdellatif, M. G. (2020). Evaluation of the preoperative administration of sildenafil on operative and early postoperative outcome after mitral valve replacement in patients with pulmonary hypertension. The Egyptian Cardiothoracic Surgeon, 2(4), 148-154.
22. Ilonze, O. J., Ebong, I. A., Guglin, M., Nair, A., Rich, J., McLaughlin, V., ... & Mazimba, S. (2024). Considerations in the diagnosis and management of pulmonary hypertension associated with left heart disease. Heart Failure, 12(8), 1328-1342.
23. Imaev, T. E., Komlev, A. E., Kuchin, I. V., Saidova, M. A., Kolegaev, A. S., Makeev, M. I., ... & Akchurin, R. S. (2022). Transcatheter mitral valve edge-to-edge repair in patients with severe mitral regurgitation: data from the MitraClip Russia Trial. Russian Journal of Cardiology, 27(2), 4689.
24. Khan, M. Z., Zahid, S., Khan, M. U., Kichloo, A., Jamal, S., Khan, A. M., ... & Balla, S. (2021). Comparison of in-hospital outcomes of transcatheter mitral valve repair in patients with vs without pulmonary hypertension (from the national inpatient sample). The American Journal of Cardiology, 153, 101-108.
25. Kopeć, G., Skride, A., Ereminiene, E., Simkova, I., Enache, R., Samarzija, M., ... & Jansa, P. (2025). Emerging therapies and new directions in the treatment of pulmonary arterial hypertension. Polish Heart Journal (Kardiologia Polska), 83(1), 18-26.
26. Kundra, T. S., Nagaraja, P. S., Bharathi, K. S., Kaur, P., & Manjunatha, N. (2018). A. Inhaled levosimendan versus intravenous levosimendan in patients with pulmonary hypertension undergoing mitral valve replacement. Annals of Cardiac Anaesthesia, 21(3), 328-332.
27. Kundra, T. S., Prabhakar, V., Kaur, P., Manjunatha, N., & Gandham, R. (2018) B. The effect of inhaled milrinone versus inhaled levosimendan in pulmonary hypertension patients undergoing mitral valve surgery—a pilot randomized double-blind study. Journal of Cardiothoracic and Vascular Anesthesia, 32(5), 2123-2129.
28. Lu, M., Wang, B., Rong, C., Wang, Y., & Zhang, W. (2025). Therapeutic challenges and new therapeutic targets for combined capillary pulmonary hypertension: a review. Frontiers in Medicine, 12, 1579112.
29. M Soliman, A. A., & Elateif El Hakeem, W. A. (2022). The role of sildenafil in perioperative management of patients with pulmonary hypertension undergoing lower limb vascular surgery. Journal of Medicine in Scientific Research, 5(3), 11.
30. Macera, F., & Vachiéry, J. L. (2021). Management of pulmonary hypertension in left heart disease. Methodist DeBakey Cardiovascular Journal, 17(2), 115.
31. Madonna, R., Biondi, F., Ghelardoni, S., D'Alleva, A., Quarta, S., & Massaro, M. (2024). Pulmonary hypertension associated to left heart disease: Phenotypes and treatment. European Journal of Internal Medicine, 129, 1-15.
32. Marcus, B., Marynen, F., Fieuws, S., Van Beersel, D., Rega, F., & Rex, S. (2023). The perioperative use of inhaled prostacyclins in cardiac surgery: a systematic review and meta-analysis. Canadian Journal of Anesthesia/Journal canadien d'anesthésie, 70(8), 1381-1393.
33. McGlothlin, D. P., Granton, J., Klepetko, W., Beghetti, M., Rosenzweig, E. B., Corris, P. A., ... & De Marco, T. (2022). ISHLT consensus statement: Perioperative management of patients with pulmonary hypertension and right heart failure undergoing surgery. The Journal of Heart and Lung Transplantation, 41(9), 1135-1194.
34. Nita, N., Tadic, M., Mörike, J., Paukovitsch, M., Felbel, D., Keßler, M., ... & Rottbauer, W. (2024). Long-term mortality after transcatheter edge-to-edge mitral valve repair significantly decreased over the last decade: comparison between initial and current experience from the MiTra ulm registry. Journal of Clinical Medicine, 13(8), 2172.
35. Patel, B., D’Souza, S., Sahni, T., & Yehya, A. (2024). Pulmonary hypertension secondary to valvular heart disease: a state-of-the-art review. Heart Failure Reviews, 29(1), 277-286.
36. Price, L. C., Martinez, G., Brame, A., Pickworth, T., Samaranayake, C., Alexander, D., ... & Wort, S. J. (2021). Perioperative management of patients with pulmonary hypertension undergoing non-cardiothoracic, non-obstetric surgery: a systematic review and expert consensus statement. British journal of anaesthesia, 126(4), 774-790.
37. Rajagopal, S., Ruetzler, K., Ghadimi, K., Horn, E. M., Kelava, M., Kudelko, K. T., ... & American Heart Association Council on Cardiopulmonary, Critical Care, Perioperative and Resuscitation, and the Council on Cardiovascular and Stroke Nursing. (2023). Evaluation and management of pulmonary hypertension in noncardiac surgery: a scientific statement from the American Heart Association. Circulation, 147(17), 1317-1343.
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Published
Sep 30, 2026
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How to Cite
Dr Suman Kr Chatterjee, & Dr Dipankar Chowdhury. (2026). INTRA-OPERATIVE AND POSTOPERATIVE OUTCOMES AND REQUIREMENT OF POSTOPERATIVE SILDENAFIL THERAPY IN PATIENTS WITH MITRAL VALVE DISEASE WITH SEVERE PULMONARY HYPERTENSION ON PREOPERATIVE ORAL SILDENAFIL THERAPY- REVIEW OF LITERATURE . Journal of Population Therapeutics and Clinical Pharmacology, 32(11), 454-471. https://doi.org/10.53555/v10a5j28
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Author Biographies
Dr Suman Kr Chatterjee
MCh(CVTS),DrNB(CVTS), Assistant professor, department of CTVS, RG Kar Medical College & Hospital, Kolkata, Email: [email protected]
Dr Dipankar Chowdhury
MS(General Surgery), MCh(CTVS) Trainee, RG Kar Medical College & Hospital, Kolkata, Email: [email protected]
How to Cite
Dr Suman Kr Chatterjee, & Dr Dipankar Chowdhury. (2026). INTRA-OPERATIVE AND POSTOPERATIVE OUTCOMES AND REQUIREMENT OF POSTOPERATIVE SILDENAFIL THERAPY IN PATIENTS WITH MITRAL VALVE DISEASE WITH SEVERE PULMONARY HYPERTENSION ON PREOPERATIVE ORAL SILDENAFIL THERAPY- REVIEW OF LITERATURE . Journal of Population Therapeutics and Clinical Pharmacology, 32(11), 454-471. https://doi.org/10.53555/v10a5j28
