Balloon pulmonary angioplasty for inoperable patients with chronic thromboembolic pulmonary hypertension: the initial German experience

Abstract

Balloon pulmonary angioplasty (BPA) is an emerging treatment for patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH).We report on a prospective series of 56 consecutive patients who underwent 266 BPA interventions (median, five per patient) at two German institutions. All patients underwent a comprehensive diagnostic work-up including right heart catheterisation at baseline and 24 weeks after their last intervention.BPA resulted in improvements in WHO functional class, 6 min walk distance (mean change, +33 m), right ventricular function and haemodynamics, including a decline in mean pulmonary artery pressure by 18% and in pulmonary vascular resistance by 26%. Procedure-related adverse events occurred in 9.4% of the interventions. The most common complications were related to pulmonary vascular injury and consecutive pulmonary bleeding. Most of these events were asymptomatic and self-limiting, but one patient died from pulmonary bleeding, resulting in a mortality rate of 1.8%.BPA resulted in haemodynamic and clinical improvements but was also associated with a considerable number of complications, including one fatal pulmonary bleeding. As the effects of BPA on survival are unknown, randomised controlled outcome trials comparing BPA with approved medical therapies in patients with inoperable CTEPH are required to allow for appropriate risk-benefit assessments.

The changing landscape of chronic thromboembolic pulmonary hypertension management

“…These positive results were maintained 1 year after the intervention [22]. Similar findings from another centre have demonstrated a positive effect of BPA on clinical and haemodynamic parameters 6 months post-BPA [57]. Improvements in a number of measures of right heart function have also been observed following BPA intervention, suggesting that this procedure contributes to reversal of right ventricular remodelling [60].…”

“…Outcomes after BPA BPA has been shown to improve symptoms, function and haemodynamic parameters in patients [21,22,[56][57][58][59][60]. Results from one experienced centre have shown an average reduction in PVR of 57% [22], as well as improvements in functional class, exercise capacity and brain natriuretic peptide levels, at 3 months post-BPA [21,22].…”

A meta‐analysis of randomized controlled trials in targeted treatments of chronic thromboembolic pulmonary hypertension

“…Second, none of the RCTs applied combination PAH‐targeted therapy that was proven to improve exercise capacity and haemodynamic status compared with monotherapy in PAH patients, making it unclear that whether combination therapy could also provide more beneficial outcomes in CTEPH population . Third, the therapeutic value of BPA was not investigated in any trial included in this analysis, which is an emerging treatment for selected patients with inoperable CTEPH . Therefore, the important questions—“which is the first treatment choice for patient with inoperable CTEPH, targeted therapy or pulmonary angioplasty?…”

New interventions to treat chronic thromboembolic pulmonary hypertension

“…However, the exact criteria for selection of patients for treatment are not clear, and many of the patients included may not be inoperable in experienced PEA surgery centres. The most recent report from a European country, with an established PEA service, comes from two German centres describing BPA in 56 consecutive patients 27. Patients underwent a total of 266 sessions (median 5), with procedure-related complications in 9.4% and one death (1.8% mortality) due to pulmonary haemorrhage.…”