Sequential Hybrid Therapy With Pulmonary Endarterectomy and Additional Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension

Abstract

BackgroundResidual symptoms after pulmonary endarterectomy (PEA) remain as the clinical issues to be solved. Additional balloon pulmonary angioplasty (BPA) after PEA showed its efficacy with symptoms in a case series, although long‐term spontaneous recovery of exercise ability after PEA was also reported. However, no studies have validated the clinical efficacy of additional BPA by directly comparing PEA with and without BPA. The aim of this study was to retrospectively evaluate the efficacy of additional BPA as a sequential hybrid therapy for chronic thromboembolic pulmonary hypertension after PEA.Methods and ResultsAmong 44 patients with chronic thromboembolic pulmonary hypertension, 20 patients had residual symptoms after PEA. Of those, 10 patients underwent additional BPA (hybrid group) and were compared with the other 10 patients, who were followed up without BPA (PEA group). The period from PEA to additional BPA was 7.3±2.3 months. In hybrid group, mean pulmonary arterial pressure was significantly improved by PEA (40.6±1.8 to 26.9±3.1 mm Hg, P=0.001) and improved further (to 16.7±1.8 mm Hg, P=0.002) with additional BPA, which resulted in remarkable improvement in World Health Organization (WHO) functional class (pre‐ to post‐BPA: class I/II/III/IV, 0/5/4/1 to 7/3/0/0; P<0.001). Compared with the PEA group at follow‐up, the hybrid group achieved better mean pulmonary arterial pressure (18.7±1.7 versus 30.2±3.2 mm Hg, P=0.008), WHO functional class (class I/II/III/IV, 7/3/0/0 versus 0/8/2/0; P=0.001), and 6‐minute walking distance (429±38 versus 319±22 m, P=0.028).ConclusionsA sequential hybrid strategy improved residual symptoms and exercise capacity compared with single‐PEA therapy.

Pulmonary Endarterectomy and Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension ― Similar Effects on Health-Related Quality of Life ―

“…In our previous reports, both extensive revascularization by BPA and sequential hybrid therapy with PEA and additional BPA contributed to amelioration of symptoms and exercise capacity in patients with CTEPH. 13 , 14 It can therefore be hypothesized that additional BPA in addition to PEA or standard BPA might lead to better HRQOL. Further investigation is required to elucidate whether additional BPA can contribute to better HRQOL in patients previously treated with PEA or BPA.…”

“… 7 – 12 In spite of the progress in therapeutic options, some patients who have undergone PEA or BPA still had residual symptoms. 13 , 14 …”

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

“…Balloon pulmonary angioplasty (BPA) is an established treatment for inoperable CTEPH [17][18][19][20][21][22][23], and previous studies have indicated that BPA may provide promising effects for residual PH after PEA [14,24,25]. The latest treatment algorithms from the Japanese Circulation Society Joint Working Group and the European Society of Cardiology guidelines also suggest BPA for symptomatic PH after PEA [7,26].…”

Balloon Pulmonary Angioplasty: State of the Art

“…[ 56 ] In addition, not all lesions are surgically accessible in any individual patient so a hybrid approach with the surgeon focusing on proximal lesions and BPA to clear distal disease has been reported. [ 68 ] Further work is required to fully characterise the population undergoing PEA and to understand where the risk benefit ratio favours a role for BPA either as part of a hybrid approach or for residual pulmonary hypertension post PEA.…”