Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension: Initial Single-Center Experience

Abstract

Objective To evaluate the safety and efficacy of balloon pulmonary angioplasty (BPA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) seen at a US medical center. Patients and Methods Patients with inoperable or residual postendarterectomy CTEPH who underwent BPA at Mayo Clinic in Rochester, Minnesota, between August 11, 2014, and May 17, 2018, were included. Invasive hemodynamic, clinical, laboratory, and echocardiographic data were collected and analyzed retrospectively. Results We identified 31 patients (26 with inoperable CTEPH and 5 with residual postendarterectomy CTEPH) who underwent 75 BPA procedures performed in a staged manner to reduce complications. The median number of sessions was 2 (interquartile range [IQR], 1-3) per patient, and the number of vessels treated per session was 3 (IQR, 2-3). Of the 31 patients, 24 (77.4%) were taking pulmonary vasodilators and 22 (71.0%) were taking riociguat. The mean pulmonary arterial pressure decreased from 40 mm Hg (IQR, 29-48 mm Hg) to 29 mm Hg (IQR, 25-37 mm Hg; P <.001); pulmonary vascular resistance decreased from 5.5 Wood units (WU) (IQR, 3.0-7.6 WU) to 3.3 WU (2.2-5.2 WU; P <.001). The follow-up 6-minute walk test was performed in 13 patients and improved from 402 m (IQR, 311-439 m) to 439 m (366-510 m; P =.001). Of the 31 patients, 19 (61.3%) had improvement in New York Heart Association functional class. The mean ± SD nadir of minute ventilation/carbon dioxide production decreased by 3.4±5.5 ( P =.03), reflecting improved ventilatory efficiency. Complications included hemoptysis requiring overnight intensive care unit observation (n=1) and cardiac tamponade requiring pericardiocentesis (n=1). One patient had reperfusion injury requiring intubation, recovered, and was dismissed to home but died unexpectedly within less than 30 days of the procedure. Serious complications occurred in 3 of the 75 BPA procedures (4.0%). Conclusion Our experience with BPA revealed that this procedure has acceptable risk and improves hemodynamics, functional class, and exercise tolerance in patients with inoperable or residual CTEPH.

Topic-Based, Recent Literature Review on Pulmonary Hypertension

“…43 An emerging option for inoperable or residual CTEPH is balloon pulmonary angioplasty (BPA). 45,46 The RACE trial compared BPA with riociguat, demonstrating a larger improvement in PVR at 26 weeks with BPA (geometric mean reduction: 60% in BPA arm, 32% in riociguat arm; P<.0001) but with more adverse effects (serious adverse events: 50% in BPA arm, 26% in riociguat arm). 46 Mayo Clinic experience with BPA was reviewed in 31 patients with inoperable CTEPH or residual CTEPH after surgical PTE.…”

“…46 Mayo Clinic experience with BPA was reviewed in 31 patients with inoperable CTEPH or residual CTEPH after surgical PTE. 45 As a viable alternative, BPA offered acceptable risks and improvement in NYHA functional class, exercise tolerance, ventilatory efficiency with improved ventilation/ perfusion mismatch, and hemodynamics. 45 Portopulmonary hypertension is a subgroup of group 1 PAH (group 1.4.3) but is often absent in PAH drug trials to avoid issues of excessive reports of hepatotoxicity, among other reasons.…”

“…45 As a viable alternative, BPA offered acceptable risks and improvement in NYHA functional class, exercise tolerance, ventilatory efficiency with improved ventilation/ perfusion mismatch, and hemodynamics. 45 Portopulmonary hypertension is a subgroup of group 1 PAH (group 1.4.3) but is often absent in PAH drug trials to avoid issues of excessive reports of hepatotoxicity, among other reasons. The ERA class has had this potential as bosentan has confirmed risk of elevated transaminases in approximately 10% of patients with group 1 PAH without previous liver disease.…”

Balloon Pulmonary Angioplasty in Patients with Chronic Thromboembolic Pulmonary Hypertension: Impact on Clinical and Hemodynamic Parameters, Quality of Life and Risk Profile

“…In comparison to Japanese centers, hemodynamic effects were lower while the occurrence of complications, including those that were fatal, were much higher. In recent years, a number of European centers (especially in Poland, Germany, France and the United Kingdom) have initiated BPA programs using the BPA technique refined in Japan [ 12 , 13 , 14 , 15 ], and first experiences were published from the Mayo Clinic in Rochester, Minnesota [ 16 ].…”

Automatic Diagnosis of Chronic Thromboembolic Pulmonary Hypertension Based on Volumetric Data from SPECT Ventilation and Perfusion Images

“…This surgical procedure involves the removal of thromboembolic material that occludes the pulmonary arteries, resulting in significant improvements in hemodynamic and right ventricular function [7]. Alternatives to endarterectomy for those patients with recurrent CTEPH, who are inoperable, or those in whom the risk-benefit ratio of pulmonary endarterectomy is unacceptable, are balloon pulmonary angioplasty [8] or anticoagulant and vasodilator pharmacological treatments, which help to dissolve the thrombus and prevent its recurrence [9]. After the treatment, the blood flow to the problematic segments should be regained, resulting in the disappearance of the hypoperfused regions in the SPECT perfusion image.…”