Sequential Hybrid Therapy With Pulmonary Endarterectomy and Additional Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension

Abstract

Background: Residual symptoms after pulmonary endarterectomy (PEA) remain as the clinical issues to be solved. Additional balloon pulmonary angioplasty (BPA) after PEA showed its efficacy with symptoms in a case series, although long-term spontaneous recovery of exercise ability after PEA was also reported. However, no studies have validated the clinical efficacy of additional BPA by directly comparing PEA with and without BPA. The aim of this study was to retrospectively evaluate the efficacy of additional BPA as a sequential hybrid therapy for chronic thromboembolic pulmonary hypertension after PEA.

Methods and results: Among 44 patients with chronic thromboembolic pulmonary hypertension, 20 patients had residual symptoms after PEA. Of those, 10 patients underwent additional BPA (hybrid group) and were compared with the other 10 patients, who were followed up without BPA (PEA group). The period from PEA to additional BPA was 7.3±2.3 months. In hybrid group, mean pulmonary arterial pressure was significantly improved by PEA (40.6±1.8 to 26.9±3.1 mm Hg, P=0.001) and improved further (to 16.7±1.8 mm Hg, P=0.002) with additional BPA, which resulted in remarkable improvement in World Health Organization (WHO) functional class (pre- to post-BPA: class I/II/III/IV, 0/5/4/1 to 7/3/0/0; P<0.001). Compared with the PEA group at follow-up, the hybrid group achieved better mean pulmonary arterial pressure (18.7±1.7 versus 30.2±3.2 mm Hg, P=0.008), WHO functional class (class I/II/III/IV, 7/3/0/0 versus 0/8/2/0; P=0.001), and 6-minute walking distance (429±38 versus 319±22 m, P=0.028).

Conclusions: A sequential hybrid strategy improved residual symptoms and exercise capacity compared with single-PEA therapy.

Keywords: balloon pulmonary angioplasty; chronic thromboembolic pulmonary hypertension; extensive revascularization; pulmonary circulation; pulmonary embolism; pulmonary endarterectomy; pulmonary hypertension; residual, persistent, or recurrent pulmonary hypertension and symptoms.

Figure 1

Observational study flow chart. BPA indicates balloon pulmonary; CTEPH, chronic thromboembolic pulmonary hypertension; PEA, pulmonary endarterectomy, WHO‐Fc, World Health Organization functional class.

Figure 2

Changes of clinical parameters by hybrid therapy. Each clinical parameter was evaluated at 4 points. Marked improvement of mPAP and PVR by PEA was followed by gradual improvement of cardiac index, 6MWD, and peak VO ₂. Additional BPA for residual pulmonary hypertension and symptoms further improved mPAP, PVR, peak VO ₂, and WHO‐Fc. 6MWD indicates 6‐minute walking distance; BPA, balloon pulmonary angioplasty; mPAP, mean pulmonary arterial pressure; PEA, pulmonary endarterectomy; PVR, pulmonary vascular resistance; VO ₂, oxygen consumption; WHO‐Fc, World Health Organization functional class.

Figure 3

Comparison of changes in clinical parameters between hybrid and PEA groups. Each clinical parameter was compared between groups. *P<0.05 between groups, ^† P<0.05 vs post‐PEA in the same group. ^†† P<0.01 vs post‐PEA in the same group. 6MWD indicates 6‐minute walking distance; mPAP, mean pulmonary arterial pressure; PEA, pulmonary endarterectomy; PVR, pulmonary vascular resistance; WHO‐Fc, World Health Organization functional class.

Figure 4

A representative case of hybrid therapy by additional BPA after PEA. Representative pulmonary angiography (A–C), dual‐energy CT (D–F), and lung ventilation–perfusion scintigraphy (G–I). PEA released the complete obstruction in the right anterior branch (right A3) and posterior basal branch (right A10), resulting in peripheral perfusion recovery in the area (white arrow). Four additional BPA sessions in the right peripheral lower lobe (right A8), upper lobe (right A3), and left lower lobe (left A8, A9, A10) improved the residual perfusion defects (black arrow). BPA indicates balloon pulmonary angioplasty; mPAP, mean pulmonary arterial pressure; PEA, pulmonary endarterectomy.