Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension

Kataoka M, Inami T, Kawakami T, Fukuda K, Satoh T.
Balloon Pulmonary Angioplasty (Percutaneous Transluminal Pulmonary Angioplasty) for Chronic Thromboembolic Pulmonary Hypertension. JACC Cardiovasc Interv 2019;12:1382-1388.

The following are key points to remember from this viewpoint article about balloon pulmonary angioplasty (BPA) for chronic thromboembolic pulmonary hypertension (CTEPH):

  • After CTEPH diagnosis is established, all patients should be evaluated by a comprehensive team of CTEPH experts including pulmonary endarterectomy–experienced surgeons.
  • In recent years, therapeutic options for CTEPH patients have expanded with the development of catheter-based interventional therapy, namely BPA.
  • European Society of Cardiology and European Respiratory Society guidelines recognize BPA as a therapeutic strategy (Class IIb recommendation) in CTEPH patients with technically inoperable disease or with unfavorable risk-to-benefit ratio for surgery.
  • BPA treatment goals are relief of pulmonary hypertension and treatment is considered complete when patients are symptom-free off pulmonary hypertension–specific drugs or no longer have obstructive lesions on pulmonary angiography. BPA for symptom relief in patients without pulmonary hypertension is unproven.

Best practice recommendations:

  • BPA should be performed using: 1) Lung perfusion scintigraphy-guidance: right lung > left lung; inferior lobe > superior or middle lobes. 2) Lesion morphology-guidance: “webs and bands” and “abrupt narrowing” > “chronic total occlusion” and “pouch defects.”
  • BPA should be staged over multiple sessions limiting contrast and radiation dose exposure (<300 cc and <1 Gy) per session.
  • Endpoints for each target lesion are: 1) Pulmonary flow grade 3. 2) Ratio of distal: proximal pressures across the target lesion (detected by pressure wire) >0.8. 3) Mean pulmonary arterial pressure distal to treated lesion does not exceed 35 mm Hg to avoid reperfusion pulmonary edema.

Keywords: Angiography, Angioplasty, Angioplasty, Balloon, Cardiac Surgical Procedures, Cardiology Interventions, Endarterectomy, Heart Failure, Hypertension, Pulmonary, Perfusion Imaging, Pulmonary Edema, Radiation Dosage, Vascular Diseases

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