Balloon Pulmonary Angioplasty for Inoperable Patients With Chronic Thromboembolic Pulmonary Hypertension. Observational Study in a Referral Unit

Velázquez, Maite; Albarrán, Agustín; Lizasoaín, Ignacio; López-Gude, María Jesús; Sarnago, Fernando; Martín, Roberto; Arribas, Fernando; Escribano, Pilar

doi:10.1016/j.rec.2018.02.020

Cited by 17 publications

(16 citation statements)

References 17 publications

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“…1). Of these, 11 studies presented outcomes for 755 patients with inoperable CTEPH treated with BPA (Table 1) 8,[22][23][24][25][26][27][28][29][30][31] . Twenty-three studies reported outcomes in 849 patients with inoperable CTEPH treated with pulmonary vasodilators (Table 1) 10-12,32-51 .…”

Section: Resultsmentioning

confidence: 99%

Comparison of Balloon Pulmonary Angioplasty and Pulmonary Vasodilators for Inoperable Chronic Thromboembolic Pulmonary Hypertension: A Systematic Review and Meta-Analysis

Kalra

Duval

Thenappan

et al. 2020

Sci Rep

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treatment options for chronic thromboembolic pulmonary hypertension (ctepH) that is not amenable to thromboendarterectomy or is recurrent/persistent after thromboendarterectomy (inoperable CTEPH) include pulmonary vasodilators or balloon pulmonary angioplasty (BPA). We compared efficacy and safety outcomes of BpA with or without pulmonary vasodilators to pulmonary vasodilator therapy alone in patients with inoperable ctepH. observational and randomized trial data reporting outcomes for >5 patients with inoperable CTEPH were sought. Single-arm random effects meta-analyses were performed. The primary outcome was change in six-minute walk distance (6MWD). Secondary outcomes included safety; World Health organization functional class (WHo fc); and change in mean pulmonary arterial pressure (mpAp), pulmonary vascular resistance (pVR), and cardiac index. thirtyfour studies with 1604 patients were eligible for analyses. Both treatments resulted in significant improvement in 6MWD (71.0 meters, 95% CI: 47.4-94.5 meters with BPA versus 47.8 meters, 95% CI: 34.5-61.2 meters with pulmonary vasodilators), PVR [−3.1 Wood Units (WU), 95% CI: −4.9 to −1.4 WU versus −1.6 WU, 95% CI: −2.4 to −0.8 WU] and mPAP (−14.8 mmHg, 95% CI: −18.2 to −11.5 mmHg versus −4.9 mmHg, 95% CI: −6.9 to −2.8 mmHg). Cardiac index was similar and most patients were WHo fc ii and iii after their respective interventions. More complications occurred in the BpA arm. In conclusion, BPA and pulmonary vasodilators both improve 6MWD and hemodynamics in patients with inoperable CTEPH. While BPA may offer greater functional and hemodynamic improvements, this technique carries the accompanying risks of an invasive procedure. Chronic thromboembolic pulmonary hypertension (CTEPH) is characterized by macrovascular obstruction due to thromboemboli with an accompanying small vessel pulmonary arteriopathy 1. Pulmonary thromboendarterectomy is the gold standard treatment for CTEPH with numerous centers of excellence worldwide 2,3. However, over 40% of CTEPH patients are ineligible for pulmonary thromboendarterectomy, due to a combination of technical inaccessibility of thromboemboli, poor surgical candidacy, patient choice, or recurrent/persistent pulmonary hypertension after the operation 4,5. CTEPH patients who are not amenable to thromboendarterectomy, develop CTEPH recurrence after thromboendarterectomy, or have persistent CTEPH despite thromboendarterectomy (inoperable CTEPH) have worse outcomes than patients who successfully undergo operative intervention 6,7. In view of this, new treatments have emerged for this patient population. Balloon pulmonary angioplasty (BPA) is a percutaneous approach that employs sequential pulmonary artery angioplasty to relieve the macrovascular obstruction associated with CTEPH 6. This approach improves exercise capacity and hemodynamics 8. Furthermore, pulmonary vasodilators

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Section: Resultsmentioning

confidence: 99%

Comparison of Balloon Pulmonary Angioplasty and Pulmonary Vasodilators for Inoperable Chronic Thromboembolic Pulmonary Hypertension: A Systematic Review and Meta-Analysis

Kalra

Duval

Thenappan

et al. 2020

Sci Rep

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“…In 2014, Fukui et al reported zero death and no major complications in 20 CTEPH patients treated with BPA (3.2 ± 0.9 sessions/patient) by treating one single lobe in the initial BPA session [ 10 ]. On the other hand, in 2018, Velázquez et al reported one death and a complication rate of 28.2% in 156 BPA sessions for 46 CTEPH patients even when only one lobe was treated in one single BPA session until mPAP ≤ 35 mmHg [ 23 ], implying that the occurrence of perioperative complication might be dictated by various factors other than the number of vessels or lobes treated per session. Although a study from Japan has described the strategy of treating both lungs in one BPA session when mPAP < 35 mmHg in 2012 [ 22 ], the safety of bilateral BPA has never been fully investigated.…”

Section: Discussionmentioning

confidence: 99%

Bilateral versus unilateral balloon pulmonary angioplasty for inoperable chronic thromboembolic pulmonary hypertension

Hong

et al. 2022

Respir Res

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Background To evaluate the safety and efficacy of bilateral balloon pulmonary angioplasty (BPA) as compared with unilateral BPA for patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH). Method We reviewed 210 consecutive BPA sessions for 92 CTEPH patients, including 124 unilateral BPA sessions and 86 bilateral BPA sessions. Radiation exposure, operation details, lesions characteristics and the occurrence of complications were compared between unilateral BPA and bilateral BPA. 131 BPA sessions with a hemodynamics follow-up were included for efficacy analysis, in which hemodynamics changes were compared. Logistic regression analysis was used to identify factors associated with the occurrence of complications. Result Bilateral BPA treated more lobes, arteries and lesions [3 (2, 4) vs. 2 (1, 3) lobes, p < 0.001; 8 (5.5, 10) vs. 6 (4, 8) vessels, p = 0.003; 9 (7, 12) vs. 8 (5, 10) lesions, p = 0.01] in one single session than unilateral BPA in a comparable operation duration and amount of contrast media given. Overall, the occurrence of complications was similar between bilateral BPA and unilateral BPA [9 (10.5%) vs. 12 (9.7%), p = 0.83]. Hemodynamics effects didn’t differ significantly between bilateral BPA and unilateral BPA in a single session [mPAP, − 4.5 ± 8.6 vs. − 3.6 ± 7.3 mmHg, p = 0.52; PVR, − 1.1 (− 3.5, 0.8) vs. − 1.8 (− 5.2, 0.3) Wood units, p = 0.21]. For the initial BPA session, bilateral BPA also treated more lobes, arteries and lesions than unilateral BPA [3 (2, 4) vs. 2 (1, 2) lobes, p < 0.001; 8.0 (5.8, 9.3) vs. 6.0 (4.0, 8.0) vessels, p = 0.04; 9 (6, 12) vs. 7 (4, 10) lesions, p = 0.02]. The occurrence of complications was also similar [5 (13.2%) vs. 5 (9.3%), p = 0.80], even in patients with poor baseline hemodynamics. Univariate regression analysis reveals the number of lobes treated/session, but not bilateral BPA, as predictive factors of complications. Conclusion Bilateral BPA may be safely and effectively performed in patients with CTEPH without increasing operation duration and radiation burden, even in patients with unfavorable baseline hemodynamics.

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“…We performed BPA according to our previously described protocol ( 4 ). All procedures were performed by three senior interventional cardiologists with experience in the treatment of patients with PH and with substantial knowledge of the pulmonary vascular tree.…”

Section: Methodsmentioning

confidence: 99%

“…We analyzed the data from an intention-to-treat perspective, considering that patients had finished BPA therapy when they completed the program according to the protocol and when they discontinued the BPA program prematurely. Residual PH was defined as a final PVR > 416 din/s/cm −5 at least 6 months after the last BPA procedure ( 4 ). The appearance of lung opacities after the procedure in the treated lobe/s was considered to indicate reperfusion edema (RPE), which was recently renamed pulmonary injury.…”

Section: Methodsmentioning

confidence: 99%

Balloon pulmonary angioplasty can be an effective and safe therapeutic option in non-surgical elderly patients

Martín

Melón

Gonzalez‐Trevilla

et al. 2022

Front. Cardiovasc. Med.

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BackgroundAdvanced age, frailty, and age-related comorbidities are the major causes of pulmonary endarterectomy disqualification in patients with chronic thromboembolic pulmonary hypertension (CTEPH). Balloon pulmonary angioplasty (BPA) is an attractive and less invasive therapy for elderly patients. However, information about the safety, procedure tolerance, and effectiveness of BPA in elderly patients is limited.Objective and methodsWe aimed to analyze the safety, tolerance, and efficacy of BPA in CTEPH patients aged ≥70 years. This observational, descriptive, and retrospective series included consecutive patients aged ≥70 years, who underwent completed or interrupted BPA programs at a pulmonary hypertension reference center between May 2013 and May 2022.ResultsWe enrolled 155 patients in our institution's BPA program. Among these, 33 patients were aged ≥70 years (mean age, 76.4 years; women, 75.8%) and had finished or interrupted BPA programs. In this cohort, we performed 116 BPA procedures (average, 3.6 ± 1.8 sessions/patient). Among the 33 patients, 19 (57.6%) completed treatment for all lobes, while the BPA program was interrupted in the remaining 14 (42.4%). Among all 33 patients, BPA was associated with a significant reduction in mean pulmonary arterial pressure (39.2 ± 9.3 vs. 32.8 ± 8.8 mmHg; p < 0.001) and pulmonary vascular resistance (6.7 ± 3.1 vs. 4.4 ± 2.0 WU; p < 0.001), along with an improvement in the cardiac index (2.5 ± 0.6 vs. 2.8 ± 0.7 L/min/m2; p = 0.04) with significant reductions in the N-terminal prohormone of brain natriuretic peptide level (pre-BPA, 353 pg/mL [207–1,960 pg/mL] vs. post-BPA, 167 pg/mL [73–629 pg/mL]; p = 0.03). The patients' functional class improved, and pulmonary hypertension-targeting drug requirements were significantly reduced. The pulmonary injury appeared in 3.4% of the 116 procedures, of which 50% were of grade 2. No patient of ≥70 years had grade 5 pulmonary injury. One periprocedural mortality was recorded (3%), and the median follow-up period was 2.8 years. The survival rate of the entire cohort at 1 and 3 years was 90.5 and 82.8%, respectively.ConclusionBPA is an effective and safe approach in patients aged ≥70 years. It significantly improves patients' functional class, hemodynamic, and biomarkers, and reduces their pulmonary hypertension-targeting medical therapy requirements. These successes were achieved even though a significant percentage of patients did not complete the therapy. The rates of procedural complications and periprocedural mortality were low. Survival at 1 and 3 years was good in comparison to that of younger patients undergoing BPA.

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Balloon Pulmonary Angioplasty for Inoperable Patients With Chronic Thromboembolic Pulmonary Hypertension. Observational Study in a Referral Unit

Cited by 17 publications

References 17 publications

Comparison of Balloon Pulmonary Angioplasty and Pulmonary Vasodilators for Inoperable Chronic Thromboembolic Pulmonary Hypertension: A Systematic Review and Meta-Analysis

Comparison of Balloon Pulmonary Angioplasty and Pulmonary Vasodilators for Inoperable Chronic Thromboembolic Pulmonary Hypertension: A Systematic Review and Meta-Analysis

Bilateral versus unilateral balloon pulmonary angioplasty for inoperable chronic thromboembolic pulmonary hypertension

Balloon pulmonary angioplasty can be an effective and safe therapeutic option in non-surgical elderly patients

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