Balloon pulmonary angioplasty for the treatment of chronic thromboembolic pulmonary hypertension: is Europe behind?

Abstract

@ERSpublicationsThe French experience of balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension is discussed in the context of international BPA experience http://bit.ly/2H6LamYCite this article as: Lang IM, Matsubara H. Balloon pulmonary angioplasty for the treatment of chronic thromboembolic pulmonary hypertension: is Europe behind? Eur Respir J 2019; 53: 1900843 [https://doi.org/10.1183/13993003.00843-2019.In their French experience of balloon pulmonary angioplasty (BPA) for chronic thromboembolic pulmonary hypertension (CTEPH), BRENOT et al.[1] describe all consecutive patients with inoperable CTEPH who underwent BPA at the French Reference Centre for Pulmonary Hypertension at Université Paris-Sud, France. All cases were discussed in a weekly multidisciplinary meeting including experienced surgeons for pulmonary endarterectomy, interventional radiologists/cardiologists, radiologists experienced in pulmonary vascular imaging and physicians with expertise in pulmonary hypertension, as recommended in the most recent ESC/ERS pulmonary hypertension guidelines [2]. In that setting, 184 patients were deemed eligible for BPA and underwent a total of 1006 BPA sessions. The authors conclude that a refined BPA strategy improves symptoms, exercise capacity and haemodynamics in inoperable CTEPH patients. This is the largest single-centre BPA experience outside of Japan to this date (the largest from Japan comprises 1408 procedures [3]). One of the other strengths is that it provides a thorough description of the procedure, and state-of-the-art peri-procedural management, for example anticoagulation. What is concerning is that results were worse than in the Japanese multicentre registry, which reported a post-procedural mean pulmonary arterial pressure (mPAP) of 22 mmHg, compared with a post-procedural mPAP of 31 mmHg in the present dataset (table 1), while pre-procedural mPAP was 43 mmHg in both datasets. Another Japanese single-centre report concluded the procedures with a post-procedural mPAP of around 20 mmHg [4], corresponding to near-normalisation of resting pressures [5]. In the German dataset that was published in 2017, final post-procedural mPAP was 33 mmHg (table 1) [6]. Other European series provide similar data [7]. Is European (French) CTEPH different? Or did the authors not seek treatment of all segments? Or were they not able to treat all segments? The precise mechanisms of diverging results remain uncertain, but some contributing factors are discussed below.After a first case report in 1988 [8] and the pivotal report from Feinstein in 2001 [9] with a discouraging 5.6% death rate, a 61% incidence of lung injury and a 17% requirement for mechanical ventilation [9],

Balloon Pulmonary Angioplasty in Technically Operable and Technically Inoperable Chronic Thromboembolic Pulmonary Hypertension

“…Within the scope of effectiveness, our results are comparable to other European series published by French and German centers [18,19], but are still slightly worse than the results achieved in Japan [20,21]. In our opinion, this is due not only to lower experience in the field of BPA, but is related to higher baseline values of pulmonary artery pressure and pulmonary vascular resistance in patients with CTEPH in the studied population [22]. Hence, interventional treatment of CTEPH may be more challenging in European centers, because higher initial pressures may indicate more severe damage to the pulmonary microcirculation.…”

Safety and efficacy of balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension in the Netherlands

“…A Japanese multicentre registry showed a more pronounced decrease in post-procedural mPAP (43 to 22 mm Hg) [13]. However, the Japanese have more experience and perform BPA in different CTEPH patients [14].…”

Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension: Clinical Outcomes

“…21,22 Overall, haemodynamic results from Japan, as shown in Table 1, appear to be better than in Europe. 23 This may be due to intrinsic differences between European and Japanese patients, with European CTEPH patients having higher serum concentrations of C-reactive protein, fibrinogen and myeloperoxidase, and more red thrombus than Japanese CTEPH patients. 24 Furthermore, because mean pulmonary arterial wedge pressures are higher in European patients due to concurrent left heart disease, mean pulmonary artery pressures tend to be higher as well.…”