Effectiveness and Safety of Balloon Pulmonary Angioplasty for the Treatment of Patients with Persistent Pulmonary Hypertension after Pulmonary Endarterectomy

Abstract

(1) Background: Pulmonary endarterectomy (PEA) is the “gold standard” treatment for operable patients with chronic thromboembolic pulmonary hypertension (CTEPH). Persistent pulmonary hypertension (PH) after PEA confers a worse prognosis. Balloon pulmonary angioplasty (BPA) could represent a useful therapy in this setting, but evidence about its effectiveness and safety in patients with previous PEA is limited. (2) Methods: A total of 14 patients with persistent PH after PEA were treated with BPA in a single PH center. Hemodynamic and clinical effects of BPA and complications of the procedure were retrospectively collected. (3) Results: After BPA, the mean pulmonary arterial pressure fell from 50.7 ± 15.3 mmHg to 38.0 ± 7.9 mmHg (25.0% decrease; 95% confidence interval (CI) 14.0–35.5%; p = 0.01). Pulmonary vascular resistances were reduced from 8.5 ± 3.6 WU to 5.3 ± 2.2 WU (37.6% decrease; 95% CI 18.8–56.5%; p = 0.01). WHO functional class was also improved with BPA. Severe BPA-related complications were infrequent and no periprocedural deaths were observed. (4) Conclusions: BPA is an effective and safe therapy for patients with CTEPH and persistent PH after PEA.

Balloon pulmonary angioplasty outcomes in patients previously treated by pulmonary endarterectomy surgery are inferior to those of inoperable patients

“…BPA for inoperable patients with CTEPH has an established evidence base 10,15,16 and planned hybrid procedures combining PEA and BPA to different lungs, where BPA targets naïve lesions that have not been endarterectomized, have also reported good results 17–19 . However, BPA for residual PH after PEA, targeting residual material “left behind” after PEA or recurrent disease has reported mixed results, with some groups demonstrating a step wise further reduction in PVR after BPA of up to 25−40%, whereas others describe negligible change or even worsening hemodynamics, as well as being technically more challenging with an increased risk of complications 14,20–23 . This study heterogeneity may be explained by differences in the degree of surgical clearance, the proportion of residual verses recurrent disease treated, differences in lesion type treated with the very distal and often occlusive residual “tails” following experienced surgical clearance perhaps responding less favorably to BPA, differences in the chronicity of the disease and a variable contribution of microvasculopathy, between the reported studies.…”