5999Comprehensive evaluation of the effectiveness and safety of balloon pulmonary angioplasty for inoperable chronic thromboembolic pulmonary hypertension - long-term effects and complications

Balloon pulmonary angioplasty (BPA) is an emerging treatment option for patients with chronic thromboembolic pulmonary hypertension (CTEPH) who have inoperable, segmental/subsegmental disease, or residual disease after pulmonary endarterectomy (PEA). In the past decade, advances in the techniques for BPA have led to better clinical outcomes with improvements in hemodynamics, pulmonary perfusion, exercise tolerance, functional capacity, and quality of life. We present the experience with BPA at our University, the largest CTEPH center in the world, followed by reviewing the published data regarding the efficacy and safety of BPA in patients with CTEPH. There is increasing evidence to support that the initial hemodynamic improvement is sustained for â¥3 years after the procedure. Although infrequent, complications observed with BPA are associated with pulmonary vascular injury or rarely reperfusion pulmonary edema. As the technique for percutaneous pulmonary artery revascularization has improved, the procedural risk and complications have continued to decrease. This promising technique continues to develop and future research is required to demonstrate the long-term benefits of BPA, standardize the technique, and define a uniform institutional infrastructure for providing BPA as a part of the treatment of CTEPH.

Download Full-text

De-escalation/discontinuation of oxygen-therapy and medication is feasible and safe in chronic thromboembolic pulmonary hypertension patients treated with balloon pulmonary angioplasty

European Heart Journal ◽

10.1093/ehjci/ehaa946.2281 ◽

2020 ◽

Vol 41 (Supplement_2) ◽

Author(s):

M Kimura ◽

T Kohno ◽

T Kawakami ◽

T Shinya ◽

T Hiraide ◽

...

Keyword(s):

Pulmonary Hypertension ◽

Clinical Outcomes ◽

Exercise Capacity ◽

Medical Therapy ◽

Functional Capacity ◽

Oxygen Therapy ◽

Chronic Thromboembolic Pulmonary Hypertension ◽

Balloon Pulmonary Angioplasty ◽

Thromboembolic Pulmonary Hypertension

Abstract Introduction There has been increasing evidence of the efficacy of balloon pulmonary angioplasty (BPA) in improving the hemodynamics, exercise capacity, and biomarkers of patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, there is no consensus on the adjustment of home oxygen therapy (HOT) and pulmonary hypertension (PH)-specific medications after BPA in patients with CTEPH. Purpose We aimed to examine the current status of the de-escalation/discontinuation of HOT and PH-specific medications post-BPA, and clarify its effect on subsequent hemodynamics, biomarkers, and long-term clinical outcomes. Methods and results From November 2012 to July 2019, 134 consecutive CTEPH patients who underwent BPA at a single university hospital were enrolled (age; 63.6±13.4 years, female; n=87 [64.9%], WHO functional class [WHO-FC] II/III/IV; 33/92/9). Hemodynamic data, functional capacity (6-minute walk distance and WHO-FC), biomarkers (brain natriuretic peptide [BNP] and high-sensitivity troponin T [hs-TropT]), and respiratory function were evaluated at baseline, immediately and 1 year post-BPA. Clinical outcomes (all-cause death and heart failure [HF] admission) were also assessed during the follow up period. The total number of sessions was 6.3±2.0, and the number of target vessels was 14.3±2.0. Mean pulmonary arterial pressure decreased from 37.8±11.2 to 20.4±5.1 mmHg 1-year after BPA (p<0.01). The proportion of patients who required HOT (at rest or on exertion) and combination medical therapy (≥2 PH-specific medications) decreased 1 year post-BPA (from 59.0% to 7.5%, and from 41.8% to 10.4%, respectively; Figure). Among 79 patients who required HOT during daytime, 64 patients (81.0%) discontinued HOT just after BPA completion. Among 56 patients who required combination medical therapy, 29 (51.8%) discontinued combination therapy. Baseline factors influencing the continuation of HOT and combination medical therapy post-BPA were almost identical (i.e. lower exercise capacity and pulmonary diffusion capacity, and worse hemodynamics). Results showed that discontinuation of HOT and combination medical therapy did not affect the maintenance of improved hemodynamics and levels of BNP and hs-TropT, and no adverse clinical outcomes (all-cause death and HF hospitalization) were observed during 1 year post-BPA. Conclusions Most CTEPH patients discontinued HOT and PH-specific combination medical therapy after BPA, which was not associated with the deterioration of hemodynamics, functional capacity, or biomarkers. No adverse long-term outcomes were observed. De-escalation/discontinuation of HOT and PH-specific combination medical therapy after BPA is feasible and safe for patients with CTEPH. De-escalation of HOT and medical therapy Funding Acknowledgement Type of funding source: None

Download Full-text

Balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension

European Respiratory Review ◽

10.1183/16000617.0119-2016 ◽

2017 ◽

Vol 26 (143) ◽

pp. 160119 ◽

Cited By ~ 89

Author(s):

Irene Lang ◽

Bernhard C. Meyer ◽

Takeshi Ogo ◽

Hiromi Matsubara ◽

Marcin Kurzyna ◽

...

Keyword(s):

Pulmonary Hypertension ◽

Fibrous Tissue ◽

Chronic Thromboembolic Pulmonary Hypertension ◽

Term Survival ◽

Percutaneous Balloon ◽

Balloon Pulmonary Angioplasty ◽

Thromboembolic Pulmonary Hypertension ◽

Pulmonary Arterial ◽

Vessel Dissection

Chronic thromboembolic pulmonary hypertension (CTEPH) is thought to result from incomplete resolution of pulmonary thromboemboli that undergo organisation into fibrous tissue within pulmonary arterial branches, filling pulmonary arterial lumina with collagenous obstructions. The treatment of choice is pulmonary endarterectomy (PEA) in CTEPH centres, which has low post-operative mortality and good long-term survival. For patients ineligible for PEA or who have recurrent or persistent pulmonary hypertension after surgery, medical treatment with riociguat is beneficial. In addition, percutaneous balloon pulmonary angioplasty (BPA) is an emerging option, and promises haemodynamic and functional benefits for inoperable patients. In contrast to conventional angioplasty, BPA with undersized balloons over guide wires exclusively breaks intraluminal webs and bands, without dissecting medial vessel layers, and repeat sessions are generally required. Observational studies report that BPA improves haemodynamics, symptoms and functional capacity in patients with CTEPH, but controlled trials with long-term follow-up are needed. Complications include haemoptysis, wire injury, vessel dissection, vessel rupture, reperfusion pulmonary oedema, pulmonary parenchymal bleeding and haemorrhagic pleural effusions. This review summarises the available evidence for BPA, patient selection, recent technical refinements and periprocedural imaging, and discusses the potential future role of BPA in the management of CTEPH.

Download Full-text

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

Journal of Clinical Medicine ◽

10.3390/jcm10051038 ◽

2021 ◽

Vol 10 (5) ◽

pp. 1038

Author(s):

Szymon Darocha ◽

Aleksander Araszkiewicz ◽

Marcin Kurzyna ◽

Marta Banaszkiewicz ◽

Stanisław Jankiewicz ◽

...

Keyword(s):

Pulmonary Hypertension ◽

Chronic Thromboembolic Pulmonary Hypertension ◽

Rank Test ◽

Log Rank Test ◽

Significant Difference ◽

Balloon Pulmonary Angioplasty ◽

Thromboembolic Pulmonary Hypertension ◽

Minute Walk ◽

Long Term Studies

Background: In this study, we aimed to assess the efficacy and safety of balloon pulmonary angioplasty (BPA) in patients with technically inoperable distal-type chronic thromboembolic pulmonary hypertension (d-CTEPH) and technically operable proximal-type disease (p-CTEPH) by analyzing the results of BPA treatment in two collaborating CTEPH referral centers. Methods and results: We assessed hemodynamic results, functional efficacy, complication and survival rate after BPA treatment in 70 CTEPH patients (median age 64 years; (interquartile range (IQR): 52–73 years)), of whom 16 (median age 73 years; (QR 62–82 years)) were in the p-CTEPH subgroup. Altogether, 377 BPA procedures were performed, resulting in significant (p < 0.001) improvement in mean pulmonary artery pressure (mPAP 48.6 ± 10 vs. 31.3 ± 8.6 mmHg), pulmonary vascular resistance (694 ± 296 vs. 333 ± 162 dynes*s*cm−5), six-minute walk test (365 ± 142 vs. 433 ± 120 metres) and N-terminal pro B-type natriuretic peptide (1307 (510–3294) vs. 206 (83–531) pg/mL). The rate of improvement did not differ between the sub-groups. Lung injury episodes and severe hemoptysis were similarly infrequent in d-CTEPH and p-CTEPH (6.4% vs. 5%; p = 0.55 and 1.0% vs. 2.5; p = 0.24, respectively). There was no significant difference between the sub-groups regarding survival (p = 0.53 by log-rank test). Conclusion: BPA may be beneficial in patients with p-CTEPH who cannot undergo pulmonary endarterectomy (PEA). Larger long-term studies are needed to better define the efficacy, safety, and optimal BPA procedural standards in this population.

Download Full-text

Soluble ST2 as a Biomarker for Early Complications in Patients with Chronic Thromboembolic Pulmonary Hypertension Treated with Balloon Pulmonary Angioplasty

Diagnostics ◽

10.3390/diagnostics11010133 ◽

2021 ◽

Vol 11 (1) ◽

pp. 133

Author(s):

Marta Banaszkiewicz ◽

Arkadiusz Pietrasik ◽

Michał Florczyk ◽

Piotr Kędzierski ◽

Michał Piłka ◽

...

Keyword(s):

Pulmonary Hypertension ◽

Troponin T ◽

Chronic Thromboembolic Pulmonary Hypertension ◽

Early Complications ◽

Dynamic Changes ◽

Soluble St2 ◽

Time Points ◽

Balloon Pulmonary Angioplasty ◽

Thromboembolic Pulmonary Hypertension ◽

Discharge From Hospital

Background: The aim of the study was to assess soluble ST2 (sST2) concentration and its dynamic changes in the periprocedural period in patients with chronic thromboembolic pulmonary hypertension (CTEPH) treated with balloon pulmonary angioplasty (BPA). Methods: We prospectively analyzed 57 procedures of BPA performed in 37 patients with CTEPH. Biomarkers, such as N-terminal pro B-type natriuretic peptide (NT-proBNP), troponin T (TnT), and sST2 were assessed at four time points: Before the BPA procedure, 24 h and 48 h after the procedure, and at the discharge from hospital. Each postprocedural period was assessed for complications. Results: Before the BPA procedure, median sST2 concentration was 26.56 ng/mL (IQR: 16.66–40.83 ng/mL). sST2 concentration was significantly higher 24 h and 48 h after the BPA compared to the baseline measurements (33.31 ng/mL (IQR: 20.81–62.56), p = 0.000 and 27.45 ng/mL (IQR: 17.66–54.45), p = 0.028, respectively). sST2 level 24 h after the BPA procedure was significantly higher in the group with complications compared to the group without complications in the postprocedural period (97.66 ng/mL (IQR: 53.07–126.18) vs. 26.86 ng/mL (IQR: 19.10–40.12), p = 0.000). Conclusions: sST2 concentration in patients with CTEPH treated with BPA changes significantly in the postprocedural period and is significantly higher in the group with complications in postprocedural period.

Download Full-text