Combined multimodal therapy in high-risk patients with chronic thromboembolic pulmonary hypertension and both distal and proximal lesions: A prospective observational cohort study

Abstract

Background: Treatments for chronic thromboembolic pulmonary hypertension (CTEPH) include PH-specific pharmacotherapy (PHSP), balloon pulmonary angioplasty (BPA), and pulmonary endarterectomy (PEA). We evaluated a sequential multimodal strategy (SMS) combining PHSP, BPA, and PEA in selected high-surgical-risk patients with distal lesions in one lung and proximal lesions in the other.

Methods: In this prospective observational study, patients were selected to the SMS by a multidisciplinary panel, based on hemodynamic severity, location of lesions, and comorbidity profile. Characteristics and complications of procedures were collected. Clinical, laboratory, and hemodynamic data were compared at baseline, before BPA, before PEA, and 6 months after PEA.

Results: We enrolled 61 patients, aged 61.9 ± 13.0 years, between 2017 and 2023. At baseline, mean pulmonary artery pressure (mPAP), cardiac output (CO), and pulmonary vascular resistance (PVR) were 49.0 ± 11.7 mmHg, 4.3 ± 1.2 L/min and 9.9 ± 4.0 WU, respectively. The most common complications were hemoptysis (13.1%) and pulmonary artery dissection (6.5%) for BPA and acute kidney injury (34.4%) and reperfusion pulmonary edema (31.1%) for PEA. The New York Heart Association functional class improved significantly and mPAP and PVR decreased significantly after each step of the strategy. Compared to baseline, the mPAP decrease was -49.4% ± 16.7% and the PVR decrease was -69.3% ± 15.9%. Three patients died in the first 2 months following surgery. The overall survival rate 14 months after PEA was 95%.

Conclusion: Our multimodal strategy was safe and effective in selected patients with severe CTEPH in whom upfront PEA was deemed unacceptably hazardous due to a high surgical risk and mixed anatomical lesions.

Keywords: Balloon pulmonary angioplasty (BPA); Chronic thromboembolic pulmonary hypertension (CTEPH); Multimodal therapy; Pulmonary endarterectomy (PEA); Pulmonary vascular disease.