Efficacy and Safety of Pulmonary Vasodilator and Inodilator Drugs in Congenital Heart Disease Surgery: A Systematic Review and Network Meta-Analysis of Randomized Controlled Trials

Abstract

Background Perioperative management of congenital heart disease (CHD) surgery presents a unique challenge due to significant pathophysiological alterations, with pulmonary hypertension contributing substantially to morbidity and mortality. Although pulmonary vasodilators and inodilators are commonly used, evidence of their efficacy and safety remains limited. Objective(s) To evaluate the effectiveness and safety of vasodilators and inodilators in paediatric patients undergoing CHD surgery. Design Systematic review with network meta-analysis. Data sources PubMed, CENTRAL, and Embase. Eligibility criteria We included single- or double-blind, parallel-group, randomised controlled trials comparing perioperative use of vasodilators and inodilators in paediatric CHD surgery. We selected only English-language studies. We excluded crossover, non-randomised trials and trials comparing the same drugs in all study arms. Results We included 28 randomised controlled trials involving 3118 patients. Intravenous levosimendan ranked highest for reducing postoperative mortality, although the effect was not statistically significant. Intravenous sildenafil and inhaled nitric oxide significantly reduced the duration of mechanical ventilation, while inhaled nitric oxide also significantly shortened ICU length of stay. Inhaled iloprost, nitric oxide, and enteral sildenafil reduced mean pulmonary artery pressure. No intervention significantly affected the incidence of acute kidney injury. Conclusions Vasodilators and inodilators did not significantly reduce perioperative mortality in paediatric CHD. Some agents, such as intravenous sildenafil and inhaled nitric oxide, demonstrated modest benefits of questionable clinical significance regarding duration of mechanical ventilation, intensive care unit stay, and pulmonary pressure. The results are limited by small sample sizes, study heterogeneity, variability in standard care, and risk of bias, requiring cautious interpretation.