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>> GOOD MORNING.
MY NAME IS BRIAN HANNA AND I'M THE DIRECTOR
OF THE PULMONARY HYPERTENSION PROGRAM AT THE CHILDREN'S
HOSPITAL OF PHILADELPHIA.
YESTERDAY WE HAD A VERY STIMULATING DISCUSSION ON
SILDENAFIL AND ITS USE IN POST-OPERATIVE CARDIAC
PATIENTS IN THE NEONATAL PERIOD.
ONE OF THE BIGGEST PROBLEMS THAT WE HAVE IN MAKING
DECISIONS WITH RESPECT TO SILDENAFIL AND OTHER
PULMONARY VESSEL DILATORS IN SMALL INFANTS
WITH PULMONARY HYPERTENSION IS THAT WE TRULY DO NOT HAVE
ANY RANDOMIZED CONTROL STUDIES TO BE ABLE TO USE
BEST PRACTICES OR EVIDENCE-BASED MEDICINE.
WE DID DISCUSS THE LITERATURE THAT IS OUT THERE NOW
THAT DEMONSTRATES THAT SILDENAFIL IS ABLE TO PUMP,
TO CAUSE VALVES OF DILATION OF THE PULMONARY TREE IN THE
POST-OPERATIVE PATIENT AND THAT IT CAN BE DONE WITH LOW
RISK AND POSSIBLY NO RISK, EXCEPT FOR THE TWO SIGNIFICANT
PROBLEMS THAT ARE-- THEY'RE NOT JUST FOR SILDENAFIL,
BUT FOR ALL NON-SELECTIVE PULMONARY VESSEL DILATORS,
MILD BLOOD PRESSURE REDUCTIONS,
AND A DECREASE IN THE OXYGENATION.
THE DECREASE IN THE OXYGENATION IS BECAUSE
OF WORSE VQ MISMATCH IN THE LUNG,
AND THE SYSTEMIC VASODILATION IS THE CAUSE
FOR THE DROP IN THE BLOOD PRESSURE.
THE PROBLEM IN SMALL INFANTS IS THAT WE HAVE TO BE VERY
CERTAIN ABOUT THE DISEASE THAT WE ARE TREATING.
SO INFANTS IN THE FIRST 30 DAYS OF AGE WHO GO
TO THE OPERATING ROOM FOR COMPLEX OR EVEN SIMPLE
CARDIAC LESIONS CAN HAVE ANY OF THE SEVERAL VERY DIFFICULT
PULMONARY ARTERIAL OR VENOUS ABNORMALITIES THAT CAUSE
PULMONARY HYPERTENSION AND OF COURSE, THOSE WILL NOT
RESPOND TO SILDENAFIL.
AND SO IN THE DISCUSSION PERIOD,
WE MADE IT VERY CLEAR BOTH FROM THE AUDIENCE AND FROM
THE PODIUM, THAT YOU HAVE TO BE VERY CAREFUL THAT IF
SOMEBODY DOES NOT RESPOND IN AN APPROPRIATE FASHION
TO EITHER NITRIC OXIDE OR TO SILDENAFIL WITH A DROP
IN THE PULMONARY ARTERY PRESSURES AND RESISTANCES,
THEN YOU MUST LOOK FOR OTHER CAUSES
FOR PULMONARY HYPERTENSION AS IN PULMONARY VEIN STENOSIS,
PULMONARY VENO-OCCLUSIVE DISEASE,
ALVEOLAR CAPILLARY DYSPLASIA,
AND THAT TYPE OF CAPILLARY AND POST-CAPILLARY DISEASE.