Balloon pulmonary angioplasty in patients with inoperable chronic thromboembolic pulmonary hypertension

Objective To examine the effect of balloon pulmonary angioplasty (BPA) on chronic thromboembolic pulmonary hypertension (CTEPH) in patients with inoperable disease or persistent pulmonary hypertension after pulmonary endarterectomy. Design Observational cohort study. Setting Referred patients with inoperable or persistent CTEPH. Patients Twenty consecutive CTEPH patients (10 females), aged 6010years. Interventions BPA. Main outcome measures Right heart catheterisation, functional capacity (cardiopulmonary exercise testing (CPET) and NYHA class) and blood sampled biomarkers N-terminal pro-brain natriuretic peptide (NT-proBNP) and troponin T examined at the time of diagnosis and repeated in all patients 3months after the last BPA. Results Seventy-three catheterisations were performed with 18.6 +/- 6.1 BPAs per patient on segmental and subsegmental arteries. Two deaths occurred following the first BPA, with an overall 10% periprocedural death rate. Reperfusion oedema complicated seven procedures. Comparisons before and after BPA showed significant haemodynamic improvements, including decreased mean pulmonary artery pressure (mPAP) (45 +/- 11mmHg vs 33 +/- 10mmHg; p<0.001) and increased cardiac output (4.9 +/- 1.6L/min vs 5.4 +/- 1.9L/min; p=0.011). Reduced right ventricular strain was indicated by significantly lower plasma levels of NT-proBNP and troponin T. Significant improvement in functional capacity was evident as assessed by NYHA class (3.0 +/- 0.5 vs 2.0 +/- 0.5; p<0.001) and CPET (13.6 +/- 5.6mL/kg/min vs 17.0 +/- 6.5mL/kg/min; p<0.001). Seventeen patients (85%) were alive after 51 +/- 30months of follow-up. Conclusions BPA may offer an alternative form of treatment in selected CTEPH patients. While prognostic markers such as haemodynamics, functional capacity and biomarkers improve, significant periprocedural complications must be recognised. Randomised trials are warranted.