Balloon Pulmonary Angioplasty for Inoperable CTEPH

Study Questions:

What are the long-term hemodynamic and prognostic effects of balloon pulmonary angioplasty (BPA) and the procedure-related complications?

Methods:

The investigators performed a total of 424 BPA sessions in 84 consecutive patients with inoperable chronic thrombo-embolic pulmonary hypertension (CTEPH) from July 2009 to October 2016. They used 3D reconstructed computed tomography to determine target lesions of pulmonary arteries and optical computed tomography to select balloon size, if needed. Hemodynamic parameters, including mean pulmonary arterial pressure (mPAP), pulmonary arterial wedge pressure, right atrial pressure, cardiac output, and pulmonary vascular resistance (PVR), were evaluated at different time points. Before hemodynamic study, exercise capacity was evaluated by 6-minute walk distance (6MWD), and serum levels of B-type natriuretic peptide (BNP) were measured at each point. Change in each parameter was compared using the paired t-test or the Wilcoxon rank sum test for continuous variables and Fisher’s exact test for categorical data, as appropriate. Five-year survival was estimated with Kaplan–Meier method and was compared between the BPA and the historical control groups with log-rank test.

Results:

In 77 patients (92%) who completed the BPA treatment (65 ± 14 [standard deviation] years old, male/female 14/63), hemodynamics and exercise capacity were examined at 6 months after last BPA and in the chronic phase (>12 months after first BPA, 31 [20, 41] months). The BPA treatment significantly improved mPAP (38 ± 10 to 25 ± 6 mm Hg), PVR (7.3 ± 3.2 to 3.8 ± 1.0 Wood units), and 6MWD (380 ± 138 to 486 ± 112 m) (all p < 0.01), and the improvements persisted throughout the follow-up period (43 ± 27 months) (n = 53). In the 424 sessions, hemoptysis was noted in 60 sessions (14%), and noninvasive positive pressure ventilation was used to treat hemoptysis and/or hypoxemia in 33 sessions (8%). Furthermore, 5-year survival was 98.4% (only one patient died of colon cancer) with no periprocedural death.

Conclusions:

The authors concluded that BPA improves hemodynamics and exercise capacity in inoperable CTEPH patients with an acceptable complication rate.

Perspective:

This study reports that in patients with inoperable CTEPH, BPA on top of optimal medical therapy significantly improves hemodynamics, exercise capacity, and plasma BNP levels. Furthermore, long-term prognosis was excellent in the patients who completed BPA with procedure-related complications at an acceptable level. Although, the beneficial effects of BPA appear durable with good long-term prognosis in this cohort study, large prospective multicenter studies comparing BPA to contemporary PH-specific drug therapy are needed.


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