Highlights from

European Respiratory Society

Congress 2018

Paris 15-19 September 2018

Balloon pulmonary angioplasty for CTEPH

Pulmonary endarterectomy (PEA) is the recommended treatment for operable patients with chronic thromboembolic pulmonary hypertension (CTEPH). However, up to 40% of them are judged as non-operable due to distal lesions or presence of comorbidities. The management of non-operable CTEPH has recently changed with the availability of effective medical therapies and balloon pulmonary angioplasty (BPA). Most of the leading CTEPH centres worldwide have currently added BPA to their therapeutic options. The current ESC/ERS guidelines state that BPA may be considered in patients with technically non-operable CTEPH [1]. However, there is no consensus about the treatment goals of BPA.

Evidence for BPA

Multiple studies performed in the last six years have shown that BPA improves clinical status and haemodynamics of non-operable CTEPH patients and is associated with a low mortality rate. Based on these findings, Dr Xavier Jaïs (Hôpitaux Universitaires Paris-Sud, France) mentioned that a refined BPA procedure could be considered as a therapeutic approach for this patient population [10-12]. In a French cohort study, which was presented during the ERS meeting, Dr Jaïs and colleagues reported that the outcomes of BPA procedures were better if the surgeons had performed more interventions in the past, providing evidence for a learning curve with respect to the efficacy and safety of this intervention. These and other aspects of BPA are discussed in more detail in a recent review article [13].

BPA-related complications

During the procedure, the main BPA-related complication is vascular injury, which can be associated with or without haemoptysis. The causes of vascular injury include wire perforation, balloon over-dilatation, and high-pressure contrast injection. Signs and symptoms of vascular injury are extravasation of contrast, hypoxaemia, cough, tachycardia, and increased pulmonary artery pressure (PAP). Another major periprocedural complication is pulmonary artery dissection. After the procedure, lung injury can develop due to vascular injury or reperfusion. It is characterised by radiographic opacity with or without haemoptysis and with or without hypoxaemia. The treatment of BPA-related lung injury depends on the severity: in case of mild lung injury, no treatment is needed; for moderate injury, supplemental oxygen; and for severe injury, ventilation is recommended. These topics were discussed during the sixth World Symposium on Pulmonary Hypertension (WSPH), which took place in February/March 2018 in Nice, France.

Outstanding issues about BPA

There are some main outstanding issues in non-operable CTEPH patients. First, there has not been an RCT comparing the safety and efficacy of medical therapy and BPA in newly diagnosed patients with non-operable CTEPH. The currently ongoing RACE study will compare riociguat and BPA in patients with non-operable CTEPH. Furthermore, it is unclear which impact medical therapy prior to BPA has on the safety and efficacy of BPA. Finally, the complementary actions and improvement in pulmonary haemodynamics and decreased risk of BPA-associated complications are unclear.

  1. Galiè N, et al. Eur Heart J. 2016;37:67-119.
  2. Mizoguchi H et al. Circ Cardiovasc Interv. 2012;5:748-55.
  3. Aoki T et al. Eur Heart J. 2017;38:3152-3159.
  4. Olsson KM et al. Eur Respir J. 2017;49(6).
  5. Ogawa A, et al. Circ J. 2018;82:1222-1230.

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