Author + information
- Christoph Liebetrau1,
- Christoph Wiedenroth1,
- Andreas Breithecker2,
- Moritz Haas1,
- Steffen Kriechbaum1,
- Stefan Guth1,
- Christian Hamm3 and
- Eckhard Mayer1
Chronic thromboembolic pulmonary hypertension (CTEPH) can be treated curatively by pulmonary endarterectomy (PEA). Up to one third of all CTEPH patients, however, are inoperable. Balloon pulmonary angioplasty (BPA) is an emerging treatment for patients with inoperable CTEPH, but little is known about the persistence of the procedural success of BPA.
Between March 2014 and October 2016 consecutive patients (n=553) with CTEPH were investigated for treatment options (PEA, BPA, medical therapy) by an interdisciplinary team consisting of thoracic surgeons, interventional cardiologists, radiologists, and pulmonologists. All patients were subjected to right- and left-heart catheterization, pulmonary angiography, 6-minute-walk test, echocardiography, spiroergometry, and a CT scan. Of 153 (27.7%) patients who were classified as inoperable, 102 patients were planned for BPA as a staged procedure. All BPAs (n=293) were performed via the femoral approach. NT-proBNP was measured in all patients before every BPA and after a 6-month follow-up period.
All patients (age 64.7 ± 13.5 yrs) were at WHO functional class III with elevated systolic RV pressure (68.2 ± 14.7 mmHg) at baseline. Almost half (46.2%) of the patients had been previously medically treated for pulmonary hypertension. During BPA we observed 6 dissections of a segment artery, which we treated conservatively. Five patients developed reperfusion oedema with the need for non-invasive ventilation. During 18 procedures patients developed hemoptysis. One patient died two weeks after hospital discharge due to hematothorax. After completion of BPA treatment (mean 5.1 [SD 1.5] procedures) in 52 patients the mean pulmonary artery pressure (mPAP) was significantly decreased (37.0 [IQR 25.5-44.0] mmHg vs. 30.0 [IQR 19.5-35.5] mmHg; P<0.0001). After BPA 80% of the patients showed an improved WHO functional class (P<0.05) and a greater 6-minute-walk distance (P<0.05). We observed a substantial decrease in NT-proBNP levels in these patients (1120.0 ng/L [IQR 215.2-1969.0] vs. 352.0 ng/L [IQR 115.4-1074.0]; P<0.0001). In patients (n=6) without a decrease in mPAP, there was no decrease in NT-proBNP (1548 ng/L [IQR 876-2236] vs. 1485 ng/L [IQR 698-2023]; P=0.67). In patients (n=29) with completed BPA treatment the significant decrease in mPAP persisted at the 6-month follow-up compared with the mPAP prior to the first BPA (30.5 [25.0-39.8] mmHg vs. 36.5 [25.0-44.5] mmHg; P=0.001). NT-proBNP decreased further after the 6-month follow-up, suggesting further right ventricular remodelling (450 ng/L [IQR 182-1327] vs. 175 ng/L [IQR 104-539]; P=0.003).
BPA is a valuable treatment option with low periprocedural risk for patients with inoperable CTEPH that shows persistent success during mid-term follow-up (survival rate 98%). Measurement of serum NT-proBNP levels allows estimation of the procedural success.
ENDOVASCULAR: Peripheral Vascular Disease and Intervention