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.
Riociguat is the treatment of choice for inoperable patients with chronic
thromboembolic pulmonary hypertension (CTEPH). We addressed here whether
additional balloon pulmonary angioplasty (BPA) provides further benefits. A
prospective series of 36 consecutive patients with inoperable CTEPH were treated
with riociguat at least three months before BPA. All patients underwent
diagnostic workup at baseline, before BPA treatments, and six months after final
intervention. The main outcome measures were pulmonary hemodynamic parameters
and World Health Organization (WHO) functional class (FC). Significant
improvements in pulmonary hemodynamics and physical capacity were observed for
riociguat treatment, and subsequent BPA interventions yielded further benefits.
With targeted medication, WHO FC improved by at least one class in 13 (36.1%)
patients (P = 0.01). Hemodynamic assessment showed significant
improvements in mean pulmonary arterial pressure (mPAP) (49 ± 12 mmHg vs.
43 ± 12 mmHg; P = 0.003) and PVR
(956 ± 501 dyn·s·cm–5 vs. 517 ± 279 dyn·s·cm–5;
P = 0.0001). Treatment with a combination of targeted
medication and BPA resulted in WHO FC improvement in 34 (94.4%) patients.
Hemodynamic assessment showed significant improvement in mPAP (43 ± 12 mmHg vs.
34 ± 14 mmHg; P = 0.0001) and PVR
(517 ± 279 dyn·s·cm–5 vs. 360 ± 175 dyn·s·cm–5;
P = 0.0001). These findings provide, for the first time,
support for the therapeutic strategy recommended by current guidelines.
Symptomatic patients with residual pulmonary perfusion defects or vascular lesions but no pulmonary hypertension at rest are diagnosed with chronic thromboembolic disease (CTED). Balloon pulmonary angioplasty (BPA) is an emerging treatment for patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH), but data regarding the safety and efficacy of BPA in patients with CTED are lacking. We report a prospective series of ten consecutive patients with CTED who underwent 35 BPA interventions (median of four per patient) at two German institutions. All patients underwent a comprehensive diagnostic workup at baseline and 24 weeks after their last intervention. BPA was safe, with one pulmonary vascular injury and subsequent self-limiting pulmonary bleeding as the only complication (2.9% of the interventions, 10% of the patients). After the procedures, World Health Organization functional class, 6-min walking distance, pulmonary vascular resistance, and pulmonary arterial compliance improved, and NT-proBNP concentrations declined in 9/10 patients. BPA may be a new treatment option for carefully selected patients with CTED. A larger, prospective, international registry is required to confirm these results.
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