Integrated Use of Perfusion SPECT/CTA Fusion Imaging and Pulmonary Balloon Angioplasty for Chronic Pulmonary Thromboembolism

Evaluation and management of patients with chronic thromboembolic pulmonary hypertension - consensus statement from the ISHLT

ISHLT members have recognized the importance of a consensus statement on the evaluation and management of patients with chronic thromboembolic pulmonary hypertension. The creation of this document required multiple steps, including the engagement of the ISHLT councils, approval by the Standards and Guidelines Committee, identification and selection of experts in the field, and the development of 6 working groups. Each working group provided a separate section based on an extensive literature search. These sections were then coalesced into a single document that was circulated to all members of the working groups. Key points were summarized at the end of each section. Due to the limited number of comparative trials in this field, the document was written as a literature review with expert opinion rather than based on level of evidence.

Balloon Pulmonary Angioplasty (Percutaneous Transluminal Pulmonary Angioplasty) for Chronic Thromboembolic Pulmonary Hypertension: A Japanese Perspective

In recent years, therapeutic options for patients with chronic thromboembolic pulmonary hypertension (CTEPH) have expanded with the development of catheter-based interventional therapy, namely balloon pulmonary angioplasty (BPA), also called percutaneous transluminal pulmonary angioplasty. For CTEPH patients with technically inoperable disease or with an unfavorable risk-to-benefit ratio for surgical pulmonary endarterectomy, BPA is an important alternative therapeutic strategy. One important treatment goal of BPA should be the relief of pulmonary hypertension. However, the indications for BPA in specialized Japanese centers currently go beyond the sole indication of relieving pulmonary hypertension. BPA is currently limited to specific institutes and experienced operators, which allows better management of its associated complications of reperfusion pulmonary edema and vascular injury using various strategies based on past experiences. This article discusses the latest indications and treatment goals of BPA and the current flow diagram for therapeutic decision-making in CTEPH, and summarizes the factors to be considered when performing BPA, from a Japanese perspective.

Balloon pulmonary angioplasty for symptomatic chronic thromboembolic disease without pulmonary hypertension at rest

BACKGROUND

Patients with chronic thromboembolic disease (CTED) have chronic thromboembolic obstructions of the pulmonary arteries with exercise intolerance, but without signs of pulmonary hypertension at rest. We investigated the efficacy of balloon pulmonary angioplasty (BPA) for CTED patients.

METHODS

Fifteen CTED patients (4 males, 11 females) who underwent BPA were enrolled. The inclusion criteria were 1) chronic thromboembolic obstructions of the pulmonary artery identified on ventilation-perfusion scans and pulmonary angiography, 2) WHO functional class II or greater, and 3) mean PAP of <25 mmHg as measured by right heart catheterization. This study excluded patients with CTEPH at diagnosis.

RESULTS

At the 6-month follow-up after the final BPA session, hemodynamics and 6-min walk distance were significantly improved. Although more than half of the patients were prescribed home oxygen therapy before BPA due to O₂ desaturation with exercise, the use ratio of home oxygen therapy was reduced at the time of follow-up (from 53% to 7%; P = 0.01). Furthermore, cardiopulmonary exercise tests during right heart catheterization demonstrated that BPA could ameliorate an abnormal pulmonary vascular response to exercise.

CONCLUSIONS

BPA can produce favorable outcomes in patients with CTED. Prospective, larger randomized clinical trials are needed to further investigate this treatment strategy.