Efficacy and safety of balloon pulmonary angioplasty for residual pulmonary hypertension after pulmonary endarterectomy

Abstract

Background: Pulmonary endarterectomy (PEA) is the standard treatment for chronic thromboembolic pulmonary hypertension (CTEPH), although some patients may experience residual pulmonary hypertension (PH). It is unclear whether balloon pulmonary angioplasty (BPA) is effective for residual PH after PEA. This study aimed to compare the BPA outcomes between patients with residual PH after PEA and those with inoperable CTEPH. Methods: This retrospective study compared BPA for residual PH after PEA (25 patients, 101 BPA sessions) and BPA alone for inoperable CTEPH (21 patients, 89 BPA sessions). All patients underwent right heart catheterisation and functional and laboratory tests before PEA or before and after BPA. Results: There was no difference in the number of BPA sessions per patient (4.0 ± 1.9 vs. 4.2 ± 1.9, p = 0.671). No significant differences were observed with respect to the mean pulmonary artery pressure (23.6 ± 9.1 vs. 21.9 ± 5.7 mmHg, p = 0.44), pulmonary vascular resistance (3.7 ± 0.5 vs. 2.8 ± 1.2 Wood units, p = 0.14), 6-min walking distance (392.1 ± 117.7 vs. 452.4 ± 90.1 m, p = 0.096), and World Health Organization functional class (I/II/ III/IV: 14/11/0/0 vs. 9/12/0/0, p = 0.375). Severe haemoptysis requiring embolisation was more common in the PH after PEA group (16.0% vs. 5.4%, p = 0.018). However, no patients required mechanical ventilation or extracorporeal membrane oxygenation, and there were no procedural deaths. Conclusion: Although BPA might be effective for residual PH after PEA, it was associated with a high rate of haemoptysis.

Balloon pulmonary angioplasty for patients with chronic thromboembolic pulmonary hypertension previously operated by pulmonary endarterectomy

“…The beneficial effects of BPA were evident in both the PEA and Non-PEA but study design and patient selection does not allow for comparison between groups. Our findings in the PEA group are, however, similar to reports from the Japanese center in Tokyo and the Polish centers 8,11 whereas the high-volume surgical center at Papworth recently reported a less favorable outcome of BPA for patients with prior PEA. 6 We know that longstanding CTEPH induces vasculopathy 17 which could limit the response to BPA in our cohort making comparison between cohorts challenging, but should encourage future efforts to shorten treatment delay.…”

“…5 Another explanation could be a higher proportion of PEA patients in our BPA cohort and that PEA patients are more prone to complications. 11 The explanation for the higher rate of complications and impaired treatment response is unknown, but with more sub-occluded lesions, larger balloons needed and a trend towards more segments treated per patient in our PEA cohort it suggests that disease burden is higher, more complex and may be more resistant to treatment and more prone to complications than Non-PEA patients.…”

“…Most patients were treated with PAH targeted therapy: PDE5 inhibitors (41%), sGC stimulators (20%) and endothelin receptor antagonists (12%). The PEA group had a longer time from CTEPH diagnosis to 1st BPA procedure (9 [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17][18] vs. 0 (0-2) years, p < 0.0001), worse lung function evaluated by FEV1/FVC (0.66 [0.57-0.71] vs. 0.72 [0.64-0.77] p = 0.05) (possible explanation being previous PEA 13 ), and more PEA patients were on PAH targeted therapy than Non-PEA (95% vs. 66%, p = 0.001). Detailed baseline characteristics are available in Table S1, but data on surgical clearance is unfortunately not available.…”

“…17 Furthermore, differences in pathobiology between European and Asian CTEPH patients may explain the difference in BPA outcome. 18 The higher volume and more experience in Japanese and the larger European centers could also explain the better results 2,4,5,11,15,19 which would suggest that BPA should be centralized to ensure highest possible operator volume and experience.…”

“…[1][2][3][4][5][6][7][8][9][10] A subset of patients are treated with BPA due to persistent pulmonary hypertension after surgical pulmonary endarterectomy (PEA), but the experience with BPA in such patients is sparse with only few reports on efficacy and safety. 6,8,11 In this research letter we report the BPA experience from Denmark including our results from CTEPH patients with prior PEA.…”