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Aggarwal V, Giri J, Visovatti SH, Mahmud E, Matsubara H, Madani M, Rogers F, Gopalan D, Rosenfield K, McLaughlin VV. Status and Future Directions for Balloon Pulmonary Angioplasty in Chronic Thromboembolic Pulmonary Disease With and Without Pulmonary Hypertension: A Scientific Statement From the American Heart Association. Circulation 2024; 149:e1090-e1107. [PMID: 38450477 DOI: 10.1161/cir.0000000000001197] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/08/2024]
Abstract
Balloon pulmonary angioplasty continues to gain traction as a treatment option for patients with chronic thromboembolic pulmonary disease with and without pulmonary hypertension. Recent European Society of Cardiology guidelines on pulmonary hypertension now give balloon pulmonary angioplasty a Class 1 recommendation for inoperable and residual chronic thromboembolic pulmonary hypertension. Not surprisingly, chronic thromboembolic pulmonary hypertension centers are rapidly initiating balloon pulmonary angioplasty programs. However, we need a comprehensive, expert consensus document outlining critical concepts, including identifying necessary personnel and expertise, criteria for patient selection, and a standardized approach to preprocedural planning and establishing criteria for evaluating procedural efficacy and safety. Given this lack of standards, the balloon pulmonary angioplasty skill set is learned through peer-to-peer contact and training. This document is a state-of-the-art, comprehensive statement from key thought leaders to address this gap in the current clinical practice of balloon pulmonary angioplasty. We summarize the current status of the procedure and provide a consensus opinion on the role of balloon pulmonary angioplasty in the overall care of patients with chronic thromboembolic pulmonary disease with and without pulmonary hypertension. We also identify knowledge gaps, provide guidance for new centers interested in initiating balloon pulmonary angioplasty programs, and highlight future directions and research needs for this emerging therapy.
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Vohra AS, Olonoff DA, Ip A, Kirtane AJ, Steinberg Z, Horn E, Krishnan U, Reisman M, Bergman G, Wong S, Feldman DN, Kim LK, Singh HS. Nationwide trends of balloon pulmonary angioplasty and pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension (2012-2019). Pulm Circ 2024; 14:e12374. [PMID: 38736894 PMCID: PMC11082429 DOI: 10.1002/pul2.12374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 03/03/2024] [Accepted: 03/19/2024] [Indexed: 05/14/2024] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a sequela of a pulmonary embolus that occurs in approximately 1%-3% of patients. Pulmonary thromboendoarterectomy (PTE) can be a curative procedure, but balloon pulmonary angioplasty (BPA) has emerged as an option for poor surgical candidates. We used the National Inpatient Sample to query patients who underwent PTE or BPA between 2012 and 2019 with CTEPH. The primary outcome was a composite of in-hospital mortality, myocardial infarction, stroke, tracheostomy, and prolonged mechanical ventilation. Outcomes were compared between low- and high-volume centers, defined as 5 and 10 procedures per year for BPA and PTE, respectively. During our study period, 870 BPA and 2395 PTE were performed. There was a 328% relative increase in the number of PTE performed during the study period. Adverse events for BPA were rare. There was an increase in the primary composite outcome for low-volume centers compared to high-volume centers for PTE (24.4% vs. 12.1%, p = 0.003). Patients with hospitalizations for PTE in low-volume centers were more likely to have prolonged mechanical ventilation (20.0%% vs. 7.2%, p < 0.001) and tracheostomy (7.8% vs. 2.6%, p = 0.017). In summary, PTE rates have been rising over the past 10 years, while BPA rates have remained stable. While adverse outcomes are rare for BPA, patients with hospitalizations at low-volume centers for PTE were more likely to have adverse outcomes. For patients undergoing treatment of CTEPH with BPA or PTE, referral to high-volume centers with multidisciplinary teams should be encouraged for optimal outcomes.
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Affiliation(s)
- Adam S. Vohra
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | | | - Ada Ip
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Ajay J. Kirtane
- Department of Medicine, Division of CardiologyColumbia University Irving Medical CenterNew YorkNew YorkUSA
| | - Zachary Steinberg
- Department of Medicine, Division of CardiologyUniversity of WashingtonSeattleWashingtonUSA
| | - Evelyn Horn
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Udhay Krishnan
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Mark Reisman
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Geoffrey Bergman
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Shing‐Chiu Wong
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Dmitriy N. Feldman
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Luke K. Kim
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
| | - Harsimran S. Singh
- Department of Medicine, Division of CardiologyWeill Cornell Medical CollegeNew YorkNew YorkUSA
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Nakazato K, Sugimoto K, Oikawa M, Takeishi Y. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension:its history and development, and regional medical cooperation in Fukushima. Fukushima J Med Sci 2023; 69:167-176. [PMID: 37766558 PMCID: PMC10694517 DOI: 10.5387/fms.2023-09] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Accepted: 08/07/2023] [Indexed: 09/29/2023] Open
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is designated as an intractable disease by the Ministry of Health, Labour and Welfare of Japan, and has an extremely poor prognosis if untreated. Surgical pulmonary endarterectomy is the curative treatment for cases in which the organized thrombi are located in the central part of the pulmonary artery, but there had been no effective treatment for cases in which the thrombi are located in the peripheral part of the pulmonary artery. Recently, balloon pulmonary angioplasty (BPA), a transcatheter procedure to dilate stenotic or occluded lesions in the peripheral pulmonary artery, has been rapidly developed. Although BPA was once a globally abandoned procedure due to hemorrhagic complications, Japanese experts have improved the technique, and its safety and efficacy have been enhanced. As a result, BPA is now being reevaluated worldwide. This review describes the history and development of BPA in the treatment of CTEPH, as well as the status of this treatment in Fukushima Prefecture.
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Affiliation(s)
- Kazuhiko Nakazato
- Regional Medical Support Center, Fukushima Medical University
- Department of Cardiovascular Medicine, Fukushima Medical University
| | - Koichi Sugimoto
- Department of Cardiovascular Medicine, Fukushima Medical University
- Futaba Emergency and General Medicine Support Center, Fukushima Medical University
| | - Masayoshi Oikawa
- Department of Cardiovascular Medicine, Fukushima Medical University
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Lang IM, Andreassen AK, Andersen A, Bouvaist H, Coghlan G, Escribano-Subias P, Jansa P, Kopec G, Kurzyna M, Matsubara H, Meyer BC, Palazzini M, Post MC, Pruszczyk P, Räber L, Roik M, Rosenkranz S, Wiedenroth CB, Redlin-Werle C, Brenot P. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension: a clinical consensus statement of the ESC working group on pulmonary circulation and right ventricular function. Eur Heart J 2023:ehad413. [PMID: 37470202 PMCID: PMC10393078 DOI: 10.1093/eurheartj/ehad413] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2022] [Revised: 05/08/2023] [Accepted: 06/12/2023] [Indexed: 07/21/2023] Open
Abstract
The current treatment algorithm for chronic thromboembolic pulmonary hypertension (CTEPH) as depicted in the 2022 European Society of Cardiology (ESC)/European Respiratory Society (ERS) guidelines on the diagnosis and treatment of pulmonary hypertension (PH) includes a multimodal approach of combinations of pulmonary endarterectomy (PEA), balloon pulmonary angioplasty (BPA) and medical therapies to target major vessel pulmonary vascular lesions, and microvasculopathy. Today, BPA of >1700 patients has been reported in the literature from centers in Asia, the US, and also Europe; many more patients have been treated outside literature reports. As BPA becomes part of routine care of patients with CTEPH, benchmarks for safe and effective care delivery become increasingly important. In light of this development, the ESC Working Group on Pulmonary Circulation and Right Ventricular Function has decided to publish a document that helps standardize BPA to meet the need of uniformity in patient selection, procedural planning, technical approach, materials and devices, treatment goals, complications including their management, and patient follow-up, thus complementing the guidelines. Delphi methodology was utilized for statements that were not evidence based. First, an anatomical nomenclature and a description of vascular lesions are provided. Second, treatment goals and definitions of complete BPA are outlined. Third, definitions of complications are presented which may be the basis for a standardized reporting in studies involving BPA. The document is intended to serve as a companion to the official ESC/ERS guidelines.
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Affiliation(s)
- Irene M Lang
- Department of Internal Medicine II, Cardiology, and Comprehensive Center of Cardiovascular Medicine CCVM, Medical University of Vienna, Währinger Gürtel 18-20, Vienna A-1090, Austria
| | - Arne K Andreassen
- Department of Cardiology, Oslo University Hospital Rikshospitalet, Pb 4950 Nydalen, 0424 Oslo, Norway
| | - Asger Andersen
- Aarhus University Hospital, Palle Juul Jensens Boulevard 99 8200 Aarhus N Denmark
| | - Helene Bouvaist
- Cardiology Department, Grenoble - Alpes University Hospital, 38043 Grenoble, France
| | - Gerry Coghlan
- Royal Free Hospital, London, Pond Street, Middlesex, London, NW3 2QG
| | | | - Pavel Jansa
- General University Hospital, U Nemocnice 2, 128 08 Prague 2, Czech Republic
| | - Grzegorz Kopec
- Pulmonary Circulation Centre Jagiellonian University Medical College, John Paul II Hospital in Krakow, Pradnicka Str. 80, 31-202 Krakow
| | - Marcin Kurzyna
- Department of Pulmonary Circulation, Thromboembolic Diseases and Cardiology Centre of Postgraduate Medical Education, EHC Otwock, Borowa 14/18, Otwock 05-400, Poland
| | - Hiromi Matsubara
- Department of Cardiology, National Hospital Organization Okayama Medical Center, 1711-1 Tamasu, Kita-ku, Okayama 701-1192, Japan
| | - Bernhard Christian Meyer
- Medizinische Hochschule Hannover - Institut für Diagnostische und Interventionelle Radiologie Carl-Neuberg-Str. 1, 30625 Hannover
| | - Massimiliano Palazzini
- Dipartimento DIMEC (Dipartimento di Scienze Mediche e Chirurgiche), Università di Bologna, 40126 Bologna, Italy
| | - Marco C Post
- Department of Cardiology, St. Antonius Hospital, Koekoekslaan 1, 3435 CM, Nieuwegein, The Netherlands
- Department of Cardiology, University Medical Center Utrecht, Heidelberglaan 100, 3584 CX, Utrecht, The Netherlands
| | - Piotr Pruszczyk
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Zwirki I Wigury 61, 02-091 Warsaw, Poland
| | - Lorenz Räber
- Department of Cardiology, Bern University Hospital, Inselspital, University of Bern Freiburgstrasse 18 3010 Bern, Switzerland
| | - Marek Roik
- Department of Internal Medicine and Cardiology, Medical University of Warsaw, Zwirki I Wigury 61, 02-091 Warsaw, Poland
| | - Stephan Rosenkranz
- Dept. of Cardiology and Cologne Cardiovascular Research Center, Heart Center at the University Hospital Cologne, Kerpener Str. 62, 50937 Köln, Germany
| | - Christoph B Wiedenroth
- Department of Thoracic Surgery, Kerckhoff Heart and Thorax Centre, Benekestrasse 2-8, 61231 Bad Nauheim, Germany
| | - Carlo Redlin-Werle
- Department of Internal Medicine II, Cardiology, and Comprehensive Center of Cardiovascular Medicine CCVM, Medical University of Vienna, Währinger Gürtel 18-20, Vienna A-1090, Austria
| | - Philippe Brenot
- Interventional Radiology Department, Marie Lannelongue Hospital, Le Plessis Robinson 92350 France
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Jain N, Perkins S, Maligireddy AR, Rosenfield K. Evolving Role and Clinical Evidence in the Global Practice of Balloon Pulmonary Angioplasty. Interv Cardiol Clin 2023; 12:417-427. [PMID: 37290844 DOI: 10.1016/j.iccl.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Balloon pulmonary angioplasty (BPA) was first described in 2001 and now has evolved into a class I indication for inoperable or residual chronic thromboembolic pulmonary hypertension. This review article aims to describe evidence from studies performed at various pulmonary hypertension (PH) centers across the globe, to better understand the role of BPA in chronic thromboembolic pulmonary disease with and without PH. Additionally, we hope to highlight innovations and the ever-changing safety and efficacy profile of BPA.
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Affiliation(s)
- Nishant Jain
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA.
| | - Sidney Perkins
- University of Michigan Medical School, Ann Arbor, MI, USA
| | | | - Kenneth Rosenfield
- Division of Cardiology, Department of Internal Medicine, Massachusetts General Hospital, Boston, MA, USA
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Kazmirczak F, Prisco SZ, Knoper R, Huddleston S, Raveendran G, Pritzker M, Thenappan T, Prins KW, Gurevich S. Effect of Combination of Balloon Pulmonary Angioplasty and Medical Therapy on Reverse Right Ventricular Remodeling and Hemodynamics in Chronic Thromboembolic Pulmonary Hypertension. THE JOURNAL OF INVASIVE CARDIOLOGY 2023; 35:E312-E320. [PMID: 37410748 PMCID: PMC10428086] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Subscribe] [Scholar Register] [Indexed: 07/08/2023]
Abstract
INTRODUCTION Chronic thromboembolic pulmonary hypertension (CTEPH) is a progressive and debilitating disorder that results from incomplete resolution of vascular obstructions resulting in pulmonary hypertension. Surgical pulmonary thromboendarterectomy (PTE) is the treatment of choice for CTEPH. Unfortunately, many CTEPH patients are ineligible for PTE or do not have access to an expert surgical center. Medical therapy imparts important symptomatic and exercise benefits for CTEPH patients, but it does not extend survival. Balloon pulmonary angioplasty (BPA) is an emerging transcatheter approach that is both safe and efficacious. However, the potential synergy between upfront BPA and medical therapy treatment approaches in patients with inoperable CTEPH is unknown. Here, we evaluated how the combination of BPA and medical therapy compared to medical therapy alone in a newly established BPA program. METHODS Twenty-one patients with inoperable or residual CTEPH were evaluated in this single-center observational study. Ten patients underwent upfront BPA and medical therapy while 11 patients were treated with medical therapy alone. Hemodynamic and echocardiographic assessments were performed at baseline and at least 1 month after completion of therapy. Continuous variables were compared using t-test or Mann-Whitney U-test. Categorical variables were analyzed with Chi squared and Fisher's exact test where appropriate. RESULTS Combination therapy significantly reduced mean pulmonary arterial pressure (mPAP) and pulmonary vascular resistance (PVR), but medical therapy only significantly lowered PVR. Comprehensive echocardiographic analysis revealed a more robust reverse right ventricular (RV) remodeling effect and augmentation of RV function with combination therapy. At the end of study, the combination therapy group had lower mPAP and PVR and better RV function. Importantly, there were no significant adverse effects in patients treated with BPA. CONCLUSION Combination therapy significantly improves hemodynamics and RV function in inoperable CTEPH while carrying an acceptable risk profile, even in a newly developed program. Further studies comparing upfront combination therapy to medical therapy with larger, long-term, and randomized approaches should be considered.
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Affiliation(s)
| | | | | | | | | | | | | | | | - Sergey Gurevich
- University of Minnesota, 401 East River Parkway, VCRC 2nd Floor, Suite 269, Minneapolis, MN 55455 USA.
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Bashir R, Noory A, Oliveros E, Romero C, Maruthi R, Mirza A, Lakhter V, Zhao H, Brisco-Bacik M, Vaidya A, Auger WR, Forfia P. Refined Balloon Pulmonary Angioplasty in Chronic Thromboembolic Pulmonary Hypertension: Initial Results of U.S. Regional Program. JACC. ADVANCES 2023; 2:100291. [PMID: 37501703 PMCID: PMC10373249 DOI: 10.1016/j.jacadv.2023.100291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 07/29/2023]
Abstract
Objectives We sought to evaluate the efficacy and safety of refined balloon pulmonary angioplasty (BPA) in the treatment of patients with chronic thromboembolic pulmonary hypertension (CTEPH). Background BPA is rapidly evolving therapeutic option for patients with nonsurgical CTEPH. There are few US studies that have reported on the outcomes of this novel therapeutic option. Methods This is a retrospective study of CTEPH patients that underwent BPA at Temple University Hospital. The primary efficacy endpoint was the change in pulmonary vascular resistance (PVR) after BPA as compared to baseline and the primary safety endpoint was the rate of hemoptysis within 24 hours. Secondary endpoints included death, WHO functional class, and 6-minute walk distance (6MWD). We used logistic regression to evaluate factors associated with a hemodynamic and functional response. Results A total of 211 BPA sessions were performed on 77 patients (average 2.7 ± 1.7 sessions/patient). After BPA the mean PVR improved by 26% (P<0.001) while the mean 6MWD improved by 71.7 meters (P <0.001) and WHO functional class improved by one functional class (P <0.001). Ten sessions (4.7%) were complicated by hemoptysis. The independent factors associated with a improved functional and hemodynamic response included the pre-procedural use of riociguat, reduce baseline PA compliance and > 3 BPA sessions per patient. Conclusion This single center study from the US showed that BPA with refined techniques in patients with CTEPH was safe and was associated with significant improvements in pulmonary hemodynamics and functional capacity.
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Affiliation(s)
- Riyaz Bashir
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Ali Noory
- Cardiovascular Institute at Allegheny Health Network, Pittsburg, PA
| | - Estefania Oliveros
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Carlos Romero
- Department of Medicine, Lewis Katz School of Medicine Temple University, Philadelphia, PA
| | - Rohit Maruthi
- Department of Medicine, Lewis Katz School of Medicine Temple University, Philadelphia, PA
| | - Arslan Mirza
- Prairie Heart Institute of Illinois, Springfield IL
| | - Vladimir Lakhter
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Huaqing Zhao
- Department of Biomedical Education and Data Science, Temple University, Philadelphia, PA
| | - Meredith Brisco-Bacik
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | - Anjali Vaidya
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
| | | | - Paul Forfia
- Division of Cardiovascular Disease, Lewis Katz School of Medicine at Temple University, Philadelphia, PA
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Jain N, Sheikh MA, Bajaj D, Townsend W, Krasuski R, Secemsky E, Chatterjee S, Moles V, Agarwal PP, Haft J, Visovatti SH, Cascino TM, Rosenfield K, Nallamothu BK, Mclaughlin VV, Aggarwal V. Periprocedural Complications With Balloon Pulmonary Angioplasty: Analysis of Global Studies. JACC Cardiovasc Interv 2023; 16:976-983. [PMID: 37100561 DOI: 10.1016/j.jcin.2023.01.361] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 12/15/2022] [Accepted: 01/10/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Balloon pulmonary angioplasty (BPA) was introduced as a treatment modality for patients with inoperable, medically refractory chronic thromboembolic pulmonary hypertension decades ago; however, reports of high rates of pulmonary vascular injury have led to considerable refinement in procedural technique. OBJECTIVES The authors sought to better understand the evolution of BPA procedure-related complications over time. METHODS The authors conducted a systematic review of original articles published by pulmonary hypertension centers globally and performed a pooled cohort analysis of procedure-related outcomes with BPA. RESULTS This systematic review identified 26 published articles from 18 countries worldwide from 2013 to 2022. A total of 1,714 patients underwent 7,561 total BPA procedures with an average follow up of 7.3 months. From the first period (2013-2017) to the second period (2018-2022), the cumulative incidence of hemoptysis/vascular injury decreased from 14.1% (474/3,351) to 7.7% (233/3,029) (P < 0.01); lung injury/reperfusion edema decreased from 11.3% (377/3,351) to 1.4% (57/3,943) (P < 0.01); invasive mechanical ventilation decreased from 0.7% (23/3,195) to 0.1% (4/3,062) (P < 0.01); and mortality decreased from 2.0% (13/636) to 0.8% (8/1,071) (P < 0.01). CONCLUSIONS Procedure-related complications with BPA, including hemoptysis/vascular injury, lung injury/reperfusion edema, mechanical ventilation, and death, were less common in the second period (2018-2022), compared with first period (2013-2017), likely from refinement in patient and lesion selection and procedural technique over time.
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Affiliation(s)
- Nishant Jain
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Muhammad A Sheikh
- Division of Cardiology, Department of Internal Medicine, Southern Illinois University School of Medicine, Springfield, Illinois, USA
| | - Divyansh Bajaj
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Whitney Townsend
- University of Michigan Taubman Health Sciences Library, Ann Arbor, Michigan, USA
| | - Richard Krasuski
- Division of Cardiology, Duke University Medical Center, Durham, North Carolina, USA
| | - Eric Secemsky
- Smith Center for Outcomes Research in Cardiology, Division of Cardiology, Department of Medicine (E.A.S.), Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Saurav Chatterjee
- Division of Cardiovascular Medicine, North Shore-Long Island Jewish Medical Centers, Northwell Health, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York, USA
| | - Victor Moles
- Division of Cardiology (Frankel Cardiovascular Center), Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Prachi P Agarwal
- Division of Cardiothoracic Radiology, Department of Radiology, University of Michigan, Ann Arbor, Michigan, USA
| | - Jonathan Haft
- Department of Cardiac Surgery, University of Michigan, Ann Arbor, Michigan, USA
| | - Scott H Visovatti
- Division of Cardiovascular Medicine, Department of Internal Medicine, The Ohio State University, Columbus, Ohio, USA
| | - Thomas M Cascino
- Division of Cardiology (Frankel Cardiovascular Center), Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Kenneth Rosenfield
- Division of Cardiology, Department of Internal Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Brahmajee K Nallamothu
- Division of Cardiology (Frankel Cardiovascular Center), Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA; Section of Cardiology, Department of Internal Medicine, Veterans Affairs Medical Center, Ann Arbor, Michigan, USA
| | - Vallerie V Mclaughlin
- Division of Cardiology (Frankel Cardiovascular Center), Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Vikas Aggarwal
- Division of Cardiology (Frankel Cardiovascular Center), Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA; Section of Cardiology, Department of Internal Medicine, Veterans Affairs Medical Center, Ann Arbor, Michigan, USA.
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Carlozzi LN, Lee J, Barros LM, Buber Y, Chen DL, Mulligan M, Ordovas K, Ralph DD, Rayner SG, Leary PJ, Steinberg ZL. Establishing a balloon pulmonary angioplasty program for chronic thromboembolic pulmonary hypertension: A United States single-center experience. Respir Med 2023; 211:107215. [PMID: 36934856 DOI: 10.1016/j.rmed.2023.107215] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 03/10/2023] [Accepted: 03/13/2023] [Indexed: 03/21/2023]
Abstract
INTRODUCTION Balloon pulmonary angioplasty (BPA) is a less invasive treatment alternative for patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are unable to move forward with pulmonary thromboendarterectomy. This report describes a single-center experience with a nascent BPA program in the United States (US). METHODS All patients who underwent BPA between August 2018-2021 were included in this retrospective, single-center observational cohort. Pre- and post-procedure clinical information was collected, along with procedural characteristics. RESULTS Thirty patients began their BPA series during the study period. The majority of patients had segmental disease (n = 25, 83.3%). A total of 135 BPA procedures were performed on 417 segments. On average, patients completed 4.5 sessions and the majority of patients (n = 23, 76.7%) underwent more than 2. There were 24 episodes of hemoptysis and 20 procedural events that required treatment, typically with either heparin reversal or balloon tamponade. Of 26 participants with completed series, mean PA pressure (-6 mmHg, 95% CI -9 to -4 mmHg, p = 0.0001), PVR (-1.9 Wood units, 95% CI -2.9 to -1.0, p = 0.0002), and pulmonary compliance (-1.0 mL/mmHg, 95% CI -1.5 to -0.5, p = 0.0002) improved. Improvement was also seen in NYHA functional classification and walk distance (p = 0.01). Two deaths occurred, with one death peri-procedurally. CONCLUSION This paper describes an early experience with BPA at a single US center. Improvement in non-invasive and invasive metrics were seen without adding a significant morbidity to an already high-risk patient population.
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Affiliation(s)
| | - Josh Lee
- Critical Care, Pulmonary and Sleep Associates, Denver, CO, USA
| | - Lia M Barros
- University of Washington, Division of Pulmonary, Critical Care, and Sleep Medicine, USA
| | - Yonatan Buber
- University of Washington, Division of Cardiology, USA
| | | | - Michael Mulligan
- University of Washington, Division of Cardiothoracic Surgery, USA
| | - Karen Ordovas
- University of Washington, Department of Radiology, USA
| | - David D Ralph
- University of Washington, Division of Pulmonary, Critical Care, and Sleep Medicine, USA
| | - Samuel G Rayner
- University of Washington, Division of Pulmonary, Critical Care, and Sleep Medicine, USA
| | - Peter J Leary
- University of Washington, Division of Pulmonary, Critical Care, and Sleep Medicine, USA; University of Washington, Department of Epidemiology, USA
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Daigo K, Katsumata Y, Esaki K, Iwasawa Y, Ichihara G, Miura K, Shirakawa K, Sato Y, Sato K, Fukuda K. Predictors of Improvement in Exercise Tolerance After Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension. J Am Heart Assoc 2023; 12:e8137. [PMID: 36718876 PMCID: PMC9973625 DOI: 10.1161/jaha.122.027395] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 10/19/2022] [Accepted: 12/06/2022] [Indexed: 02/01/2023]
Abstract
Background Balloon pulmonary angioplasty (BPA) improves exercise tolerance and hemodynamic parameters in patients with chronic thromboembolic pulmonary hypertension. However, it is still unclear which patient characteristics contribute to the improvement in exercise tolerance after BPA in chronic thromboembolic pulmonary hypertension. Methods and Results We retrospectively analyzed 126 patients with chronic thromboembolic pulmonary hypertension (aged 63±14 years; female, 65%) who underwent BPA without concomitant programmed exercise rehabilitation at Keio University between November 2012 and April 2018. Hemodynamic data and 6-minute walk distance (6MWD), as a measure of exercise tolerance, were evaluated before and 1 year after BPA. The clinical characteristics that contributed to improvement in exercise tolerance were elucidated. The 6MWD significantly increased from 372.0 m (256.5-431.3) to 462.0 m (378.8-537.0) 1 year after BPA (P<0.001). The improvement rate in the 6MWD after BPA exhibited a good correlation with age, height, mean pulmonary artery pressure, and 6MWD at baseline (Spearman rank correlation coefficients=-0.28, 0.24, -0.40, and 0.44, respectively). Additional multivariable linear regression analysis revealed that young age, tall height, high mean pulmonary artery pressure, short 6MWD at baseline, and high lung capacity at baseline were significant predictors of the improvement in 6MWD by BPA (standardized partial regression coefficient -0.39, 0.22, 0.19, -0.62, and 0.25, P<0.001, 0.007, 0.011, <0.001, and <0.001, respectively). Conclusions BPA without concomitant programmed exercise rehabilitation significantly improves exercise tolerance. This was particularly true in young patients with high stature, high mean pulmonary artery pressure, short 6MWD, and lung capacity at the time of diagnosis.
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Affiliation(s)
- Kyohei Daigo
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | | | - Kosho Esaki
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Yuji Iwasawa
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Genki Ichihara
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Kotaro Miura
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Kohsuke Shirakawa
- Department of CardiologyKeio University School of MedicineTokyoJapan
| | - Yasunori Sato
- Department of Preventive Medicine and Public HealthKeio University School of MedicineTokyoJapan
| | - Kazuki Sato
- Institute for Integrated Sports Medicine, Keio University School of MedicineTokyoJapan
| | - Keiichi Fukuda
- Department of CardiologyKeio University School of MedicineTokyoJapan
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11
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Kennedy MK, Kennedy SA, Tan KT, de Perrot M, Bassett P, McInnis MC, Thenganatt J, Donahoe L, Granton J, Mafeld S. Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension: A Systematic Review and Meta-analysis. Cardiovasc Intervent Radiol 2023; 46:5-18. [PMID: 36474104 DOI: 10.1007/s00270-022-03323-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 11/16/2022] [Indexed: 12/12/2022]
Abstract
PURPOSE To perform a systematic review and meta-analysis assessing the safety and efficacy of balloon pulmonary angioplasty (BPA) in the treatment of chronic thromboembolic pulmonary hypertension (CTEPH). MATERIALS AND METHODS Systematic literature searches were performed from inception to June 2022 to identify studies assessing BPA for CTEPH. Outcomes of interest included the following functional and hemodynamic measures: (a) six-minute walk distance (6MWD), (b) New York Heart Association (NYHA) status, (c) World Health Organization (WHO)-Functional Class status, (d) cardiac index (CI), (e) mean pulmonary artery pressure (mPAP), (f) mean right atrial pressure (mRAP), and (g) pulmonary vascular resistance (PVR). Subgroup analysis was also performed for BPA in post-pulmonary endarterectomy (PEA) patients. All reported BPA-related complications were also recorded. Forty unique studies with a total of 1763 patients were identified for meta-analysis. RESULTS All functional and hemodynamic parameters improved significantly following BPA; 6MWD increased 70 m (95% CI 58-82; P < 0.001), NYHA class improved by - 0.9 classes (95% CI - 1.0 to - 0.8; P < 0.001), WHO-FC class improved by - 1 classes ((95% CI - 1.2 to - 0.9; P < 0.001), CI increased 0.26 L/min/m2 (95% CI 0.17-0.35; P < 0.001), mPAP decreased - 13.2 mmHg (95% CI - 14.7 to - 11.8; P < 0.001), mRAP decreased - 2.2 mmHg (95% CI - 2.8 to - 1.6; P < 0.001), and PVR decreased - 311 dyne/cm/s-5 (95% CI - 350 to - 271; P < 0.001). Meta-analysis of patients who underwent BPA for persistent pulmonary hypertension post-PEA demonstrated significant improvements in 6MWD, WHO-FC, PVR and mPAP. Most common complications included lung injury (8.16%), hemoptysis (7.07%) and vessel injury (5.05%). CONCLUSION BPA represents a safe and effective treatment option for select individuals with CTEPH with significant improvements in hemodynamic parameters, improved exercise tolerance and a relatively low risk of major complications.
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Affiliation(s)
- Mary K Kennedy
- Department of Medical Imaging, University of Toronto, 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada
| | - Sean A Kennedy
- Department of Medical Imaging, University of Toronto, 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada.
| | - Kong Teng Tan
- Department of Medical Imaging, University of Toronto, 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada
| | - Marc de Perrot
- Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada
| | - Paul Bassett
- Statsconsultancy Ltd, Amersham, Buckinghamshire, UK
| | - Michael C McInnis
- Department of Medical Imaging, University of Toronto, 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada
| | - John Thenganatt
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | | | - John Granton
- Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Sebastian Mafeld
- Department of Medical Imaging, University of Toronto, 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada
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12
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Oka T, Nakanishi R, Kabuki T, Hashimoto H, Fujii T, Dobashi S, Ikeda T. Appropriate Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension Improves Right Ventricular Ejection Fraction via Lung Perfusion Scan. Int Heart J 2022; 63:91-98. [DOI: 10.1536/ihj.21-437] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Takashi Oka
- Department of Cardiovascular Medicine, Toho University Graduate School of Medicine
| | - Rine Nakanishi
- Department of Cardiovascular Medicine, Toho University Graduate School of Medicine
| | - Takayuki Kabuki
- Division of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine
| | - Hidenobu Hashimoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine
| | - Takahiro Fujii
- Division of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine
| | - Shintarou Dobashi
- Division of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine
| | - Takanori Ikeda
- Department of Cardiovascular Medicine, Toho University Graduate School of Medicine
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13
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Akaslan D, Ataş H, Aslanger E, Kanar BG, Kocakaya D, Yıldızeli B, Mutlu B. Change in pulmonary arterial compliance and pulmonary pulsatile stress after balloon pulmonary angioplasty. Anatol J Cardiol 2022; 26:43-48. [PMID: 35191385 PMCID: PMC8878948 DOI: 10.5152/anatoljcardiol.2021.149] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/29/2021] [Indexed: 07/29/2023] Open
Abstract
OBJECTIVE Although the underlying pathology of chronic thromboembolic pulmonary hypertension (CTEPH) is mechanical obliteration of the major pulmonary vessels, high pulsatile stress penetrating into the normal distal pulmonary microvasculature resulting from reduced pulmonary arterial compliance (CPA) may cause progressive deterioration in pulmonary hemodynamics. Hypothetically, balloon pulmonary angioplasty (BPA) may be beneficial in reducing CPA and pulsatile stress in patients with CTEPH. METHODS In total, 26 patients with available pre- and post-BPA right heart catheterization results were included in the study. BPA was performed in a series of staged procedures by 2 experienced interventional cardiologists. RESULTS The median CPA showed a 59.2% increase (1.03 to 1.64 mL/mm Hg, p=0.005). The median pre-BPA pulsatile stress product decreased by 20.7% (4,266 to 3,380 mm Hg/min, p=0.003). A linear regression model established that the percent change in CPA after BPA accounted for 21.8% of the explained variability in the change in 6-minute walk test (p=0.009). CONCLUSION Our results indicate that BPA decreases CPA and pulmonary pulsatile stress. These changes may be partly responsible for the improvement in functional capacity after BPA.
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Affiliation(s)
- Dursun Akaslan
- Department of Cardiology, Marmara University, Pendik Training and Research Hospital; İstanbul-Turkey
| | - Halil Ataş
- Department of Cardiology, Marmara University, Pendik Training and Research Hospital; İstanbul-Turkey
| | - Emre Aslanger
- Department of Cardiology, Marmara University, Pendik Training and Research Hospital; İstanbul-Turkey
| | - Batur Gönenç Kanar
- Department of Cardiology, Marmara University, Pendik Training and Research Hospital; İstanbul-Turkey
| | - Derya Kocakaya
- Department of Pulmonology, Marmara University, Pendik Training and Research Hospital; İstanbul-Turkey
| | - Bedrettin Yıldızeli
- Department of Thoracic Surgery, Marmara University, Pendik Training and Research Hospital; İstanbul-Turkey
| | - Bülent Mutlu
- Department of Cardiology, Marmara University, Pendik Training and Research Hospital; İstanbul-Turkey
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14
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Taweel H, Haddadin I, Heresi G. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension. JAAPA 2022; 35:21-27. [PMID: 34908560 DOI: 10.1097/01.jaa.0000803620.44399.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
ABSTRACT Chronic thromboembolic pulmonary hypertension (CTEPH) remains significantly underdiagnosed in patients with a history of pulmonary embolism. These patients complain of persistent shortness of breath and present with hypoxemia despite proper anticoagulation. Further investigation reveals evidence of right ventricular dysfunction on echocardiogram, which progresses to right heart failure. CTEPH is associated with a significant increase in patient morbidity and mortality if left untreated. This article offers an approach for the timely recognition of this condition, in addition to suggesting a management protocol with an emphasis on the role of interventional radiology and balloon pulmonary angioplasty.
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Affiliation(s)
- Helwa Taweel
- At the Cleveland (Ohio) Clinic, Helwa Taweel practices in Interventional radiology, Ihab Haddadin is an interventional radiologist, and Gustavo Heresi is director of the pulmonary vascular and chronic thromboembolic pulmonary hypertension program. The authors have disclosed no potential conflicts of interest, financial or otherwise
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15
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Burger CD, DuBrock HM, Cartin-Ceba R, Moss JE, Shapiro BP, Frantz RP. Topic-Based, Recent Literature Review on Pulmonary Hypertension. Mayo Clin Proc 2021; 96:3109-3121. [PMID: 34479734 DOI: 10.1016/j.mayocp.2021.05.026] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2021] [Revised: 05/25/2021] [Accepted: 05/28/2021] [Indexed: 01/22/2023]
Abstract
Pulmonary hypertension is a complex condition but a relatively common manifestation of severe cardiopulmonary disease. By contrast, pulmonary arterial hypertension is uncommon and is more prevalent in young women. To better categorize patients and to guide clinical decision-making, 5 diagnostic groups and associated subgroups characterize the spectrum of disease. A multidisciplinary approach to evaluation and treatment is recommended by published guidelines and often entails referral to a designated pulmonary hypertension center. Several key publications during the last couple of years merit review. The PubMed database was searched for English-language studies and guidelines relating to pulmonary hypertension. The following terms were searched, alone and in combination: pulmonary hypertension, pulmonary arterial hypertension, portopulmonary hypertension, and chronic thromboembolic pulmonary hypertension. The focus was on those publications with new information on evaluation and management of pulmonary hypertension between January 1, 2019, and January 31, 2021. Of the subgroups, 2 were of particular interest for this review: portopulmonary hypertension and chronic thromboembolic pulmonary hypertension. Last, available data on the impact of the coronavirus disease 2019 pandemic and newer treatment agents in early trials were selectively reviewed. The review is therefore intended to serve as a practical, focused review of important topics germane to those clinicians caring for patients with pulmonary hypertension.
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Affiliation(s)
- Charles D Burger
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL.
| | - Hilary M DuBrock
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN
| | - Rodrigo Cartin-Ceba
- Division of Pulmonary Medicine, Mayo Clinic, Scottsdale, AZ; Department of Critical Care Medicine, Mayo Clinic, Scottsdale, AZ
| | - John E Moss
- Division of Pulmonary, Allergy and Sleep Medicine, Mayo Clinic, Jacksonville, FL; Department of Critical Care Medicine, Mayo Clinic, Jacksonville, FL
| | - Brian P Shapiro
- Department of Cardiovascular Medicine, Mayo Clinic, Jacksonville, FL
| | - Robert P Frantz
- Department of Cardiovascular Medicine, Mayo Clinic, Rochester, MN
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16
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Peters AC, Madhan AS, Kislitsina O, Elenbaas C, Nishtala A, Freed B, Schimmel D, Thomas JD, Cuttica M, Malaisrie SC. Temporal trends in right heart strain in patients undergoing pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension. Echocardiography 2021; 38:1932-1940. [PMID: 34747056 DOI: 10.1111/echo.15246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Revised: 10/14/2021] [Accepted: 10/21/2021] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Pulmonary thromboendarterectomy (PTE) is a curative procedure for chronic thromboembolic pulmonary hypertension (CTEPH). Right ventricular free wall strain (RV FWS) and right atrial strain (RAS) are not well studied in a CTEPH population. We sought to determine temporal trends in RAS and RV FWS in patients post-PTE. METHODS 28 patients undergoing PTE for CTEPH were prospectively enrolled in a surgical database. Comprehensive echocardiographic assessment of the right heart was performed including RV FWS, right atrial volume, and the three components of RAS: reservoir, conduit, and booster strain. RESULTS Patients undergoing PTE demonstrated improvement in NYHA functional class (P < 0.001). Hemodynamic assessment showed improvement in mean pulmonary artery pressure from 49.7 ± 8.5 mm Hg to 23.9 ± 6.5 mm Hg (P < 0.001) and pulmonary vascular resistance decreased from 7.8 ± 3.2 wu to 2.4 ± 1.3 wu (P < 0.001). Tricuspid annular plane systolic excursion (TAPSE) and lateral S` declined immediately post-op. RV FWS improved from -14.4 ± 4% to -19 ± 3.4% post-op and -21.2 ± 4.7% at long-term follow-up (P < 0.001). Improvement in RV FWS post-op was driven primarily by increases in the apical and mid segments. RA volume declined significantly during the study period. RA reservoir and conduit strain improved after PTE. CONCLUSION Patients undergoing PTE for CTEPH had significant improvement in right heart hemodynamics immediately post-op. Traditional echo metrics of RV performance including TAPSE and lateral S` did not improve. RV FWS improved, which was driven by changes in the apical and mid segments. This highlights that RV FWS is a viable and useful metric to follow in CTEPH patients post-PTE.
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Affiliation(s)
- Andrew C Peters
- Feinberg School of Medicine at Northwestern University, Division of Cardiology, Chicago, Illinois, USA
| | - Ashwin Shaan Madhan
- Feinberg School of Medicine at Northwestern University, Division of Cardiology, Chicago, Illinois, USA
| | - Olga Kislitsina
- Feinberg School of Medicine at Northwestern University, Division of Cardiothoracic Surgery, Chicago, Illinois, USA
| | - Christian Elenbaas
- Feinberg School of Medicine at Northwestern University, Division of Cardiothoracic Surgery, Chicago, Illinois, USA
| | - Arvind Nishtala
- Feinberg School of Medicine at Northwestern University, Division of Cardiology, Chicago, Illinois, USA
| | - Benjamin Freed
- Feinberg School of Medicine at Northwestern University, Division of Cardiology, Chicago, Illinois, USA
| | - Daniel Schimmel
- Feinberg School of Medicine at Northwestern University, Division of Cardiology, Chicago, Illinois, USA
| | - James D Thomas
- Feinberg School of Medicine at Northwestern University, Division of Cardiology, Chicago, Illinois, USA
| | - Michael Cuttica
- Feinberg School of Medicine at Northwestern University, Division of Pulmonology, Chicago, Illinois, USA
| | - S Christopher Malaisrie
- Feinberg School of Medicine at Northwestern University, Division of Cardiothoracic Surgery, Chicago, Illinois, USA
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17
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de Perrot M, Gopalan D, Jenkins D, Lang IM, Fadel E, Delcroix M, Benza R, Heresi GA, Kanwar M, Granton JT, McInnis M, Klok FA, Kerr KM, Pepke-Zaba J, Toshner M, Bykova A, Armini AMD, Robbins IM, Madani M, McGiffin D, Wiedenroth CB, Mafeld S, Opitz I, Mercier O, Uber PA, Frantz RP, Auger WR. Evaluation and management of patients with chronic thromboembolic pulmonary hypertension - consensus statement from the ISHLT. J Heart Lung Transplant 2021; 40:1301-1326. [PMID: 34420851 DOI: 10.1016/j.healun.2021.07.020] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 07/22/2021] [Indexed: 02/08/2023] Open
Abstract
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.
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Affiliation(s)
- Marc de Perrot
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada.
| | - Deepa Gopalan
- Department of Radiology, Imperial College Healthcare NHS Trust, London & Cambridge University Hospital, Cambridge, UK
| | - David Jenkins
- National Pulmonary Endarterectomy Service, Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
| | - Irene M Lang
- Department of Cardiology, Pulmonary Hypertension Unit, Medical University of Vienna, Vienna, Austria
| | - Elie Fadel
- Department of Thoracic and Vascular Surgery and Heart Lung Transplantation, Marie-Lannelongue Hospital, Paris Saclay University, Le Plessis-Robinson, France
| | - Marion Delcroix
- Clinical Department of Respiratory Diseases, Pulmonary Hypertension Centre, UZ Leuven, Leuven, Belgium; Laboratory of Respiratory Diseases and Thoracic Surgery (BREATHE), Department of Chronic Diseases and Metabolism (CHROMETA), KU, Leuven, Belgium
| | - Raymond Benza
- Division of Cardiovascular Medicine, The Ohio State University, Columbus, Ohio
| | - Gustavo A Heresi
- Department of Pulmonary and Critical Care Medicine, Respiratory Institute, Cleveland Clinic, Cleveland, Ohio
| | - Manreet Kanwar
- Cardiovascular Institute, Allegheny Health Network, Pittsburgh, Pennsylvania
| | - John T Granton
- Division of Respirology, University Health Network, Toronto, Ontario, Canada
| | - Micheal McInnis
- Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Frederikus A Klok
- Department of Medicine, Thrombosis and Hemostasis, Leiden University Medical Center, Leiden, The Netherlands
| | - Kim M Kerr
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Joanna Pepke-Zaba
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, UK
| | - Mark Toshner
- Pulmonary Vascular Disease Unit, Royal Papworth Hospital NHS foundation Trust, Cambridge, Cambridgeshire, UK; Heart Lung Research Institute, University of Cambridge, Cambridge, UK
| | - Anastasia Bykova
- Division of Thoracic Surgery, Toronto General Hospital, Toronto, Ontario, Canada
| | - Andrea M D' Armini
- Unit of Cardiac Surgery, Intrathoracic-Trasplantation and Pulmonary Hypertension, University of Pavia, Foundation I.R.C.C.S. Policlinico San Matteo, Pavia, Italy
| | - Ivan M Robbins
- Division of Allergy, Pulmonary, and Critical Care Medicine, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael Madani
- Department of Cardiovascular and Thoracic Surgery, University of California San Diego, La Jolla, California
| | - David McGiffin
- Department of Cardiothoracic Surgery, The Alfred Hospital and Monash University, Melbourne, VIC, Australia
| | - Christoph B Wiedenroth
- Department of Thoracic Surgery, Campus Kerckhoff of the University of Giessen, Kerckhoff Heart and Thorax Center, Bad Nauheim, Germany
| | - Sebastian Mafeld
- Division of Vascular and Interventional Radiology, Joint Department of Medical Imaging, University Health Network, Toronto, Ontario, Canada
| | - Isabelle Opitz
- Department of Thoracic Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Olaf Mercier
- Department of Thoracic and Vascular Surgery and Heart Lung Transplantation, Marie-Lannelongue Hospital, Paris Saclay University, Le Plessis-Robinson, France
| | - Patricia A Uber
- Pauley Heart Center, Virginia Commonwealth University Health System, Richmond, Virginia
| | - Robert P Frantz
- Department of Cardiovascular Disease, Mayo Clinic College of Medicine, Rochester, Minnesota
| | - William R Auger
- Pulmonary Hypertension and CTEPH Research Program, Temple Heart and Vascular Institute, Temple University, Lewis Katz School of Medicine, Philadelphia, Pennsylvania
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18
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Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension: advances in patient and lesion selection. Curr Opin Pulm Med 2021; 27:303-310. [PMID: 34224432 DOI: 10.1097/mcp.0000000000000797] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
PURPOSE OF REVIEW Balloon pulmonary angioplasty (BPA) has been performed worldwide for patients who are ineligible for pulmonary endarterectomy (PEA). However, the technical details of BPA have not been standardized, and no international consensus regarding patient and lesion selection for BPA has been reached. Evidence for the combination of BPA with PEA or medical therapy is also lacking. This review highlights recent progress in BPA in terms of patient and lesion selection and the current procedural approach for BPA, including combination treatment. RECENT FINDINGS The indications for BPA have expanded with recent reports describing the improved safety and efficacy of BPA. Because lesions are generally present in all segmental and subsegmental pulmonary arteries, it is recommended to treat all the lesions to achieve desirable hemodynamic improvement. Selective pulmonary angiography is the gold standard for lesion selection in modern BPA aimed at total revascularization. Despite the lack of randomized controlled studies, combination treatment with BPA may be well tolerated and effective. SUMMARY BPA, alone or in combination with PEA or medical therapy, may be a treatment option for patients who are not candidates for monotreatment of PEA. However, further investigation is required to standardize patient and lesion selection for BPA.
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19
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Lloji A, Hooda U, Sreenivasan J, Malekan R, Aronow WS, Lanier GM. Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension. AMERICAN JOURNAL OF CARDIOVASCULAR DISEASE 2021; 11:330-347. [PMID: 34322303 PMCID: PMC8303037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 05/08/2021] [Indexed: 06/13/2023]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is a form of pulmonary hypertension (PH) caused by thromboembolic disease with the secondary remodeling of the pulmonary vessels. The primary treatment of CTEPH is pulmonary thromboendarterectomy (PTE). However, some patients are not candidates for PTE because of surgically inaccessible thrombi or high operative risk and can be candidates for balloon pulmonary angioplasty (BPA), an emerging, lower risk treatment. This review discusses the patient selection, the technique, and comprehensive review of reported outcomes following BPA. BPA techniques have improved over the years, and so has its safety profile. Recent data show that after several sessions of BPA, patients who were not eligible for PTE had improvement in their hemodynamic profile, functional capacity, and 6-minute walk distance. Studies have shown that compared to riociguat, BPA has shown significant improvement in the functional capacity and hemodynamic measurements. Reperfusion pulmonary edema is a common complication after PTE and BPA, which may be due to vessel injury rather than pulmonary extravasation. Rates of complications have decreased especially after the use of optical coherence tomography, which helps in proper sizing of the balloons. Patients with CTEPH who are ineligible for PTE should be evaluated for BPA. In addition to medical therapy, BPA has shown promising clinical and hemodynamic outcomes in patients with CTEPH.
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Affiliation(s)
- Amanda Lloji
- Department of Cardiology, Westchester Medical Center and New York Medical CollegeValhalla, New York, The United States
| | - Urvashi Hooda
- Department of Cardiology, Westchester Medical Center and New York Medical CollegeValhalla, New York, The United States
| | - Jayakumar Sreenivasan
- Department of Cardiology, Westchester Medical Center and New York Medical CollegeValhalla, New York, The United States
| | - Ramin Malekan
- Division of Cardiothoracic Surgery, Westchester Medical Center, New York Medical CollegeValhalla, New York, The United States
| | - Wilbert S Aronow
- Department of Cardiology, Westchester Medical Center and New York Medical CollegeValhalla, New York, The United States
| | - Gregg M Lanier
- Department of Cardiology, Westchester Medical Center and New York Medical CollegeValhalla, New York, The United States
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20
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Papamatheakis DG, Poch DS, Fernandes TM, Kerr KM, Kim NH, Fedullo PF. Chronic Thromboembolic Pulmonary Hypertension: JACC Focus Seminar. J Am Coll Cardiol 2021; 76:2155-2169. [PMID: 33121723 DOI: 10.1016/j.jacc.2020.08.074] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Revised: 08/27/2020] [Accepted: 08/29/2020] [Indexed: 11/28/2022]
Abstract
Chronic thromboembolic pulmonary hypertension (CTEPH) is the result of pulmonary arterial obstruction by organized thrombotic material stemming from incompletely resolved acute pulmonary embolism. The exact incidence of CTEPH is unknown but appears to approximate 2.3% among survivors of acute pulmonary embolism. Although ventilation/perfusion scintigraphy has been supplanted by computed tomographic pulmonary angiography in the diagnostic approach to acute pulmonary embolism, it has a major role in the evaluation of patients with suspected CTEPH, the presence of mismatched segmental defects being consistent with the diagnosis. Diagnostic confirmation of CTEPH is provided by digital subtraction pulmonary angiography, preferably performed at a center familiar with the procedure and its interpretation. Operability assessment is then undertaken to determine if the patient is a candidate for potentially curative pulmonary endarterectomy surgery. When pulmonary endarterectomy is not an option, pulmonary arterial hypertension-targeted pharmacotherapy and balloon pulmonary angioplasty represent potential therapeutic alternatives.
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Affiliation(s)
- Demosthenes G Papamatheakis
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - David S Poch
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Timothy M Fernandes
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Kim M Kerr
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Nick H Kim
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California
| | - Peter F Fedullo
- University of California San Diego Medical Health, Division of Pulmonary Critical Care and Sleep Medicine, San Diego, California.
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Balloon Pulmonary Angioplasty in Patients with Chronic Thromboembolic Pulmonary Hypertension: Impact on Clinical and Hemodynamic Parameters, Quality of Life and Risk Profile. J Clin Med 2020; 9:jcm9113608. [PMID: 33182415 PMCID: PMC7697583 DOI: 10.3390/jcm9113608] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2020] [Revised: 11/05/2020] [Accepted: 11/06/2020] [Indexed: 12/01/2022] Open
Abstract
Balloon pulmonary angioplasty (BPA) is a novel treatment option for patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are not eligible for pulmonary endarterectomy (PEA) or suffer from persistent pulmonary hypertension after PEA. The aim of this study was to evaluate the real-life efficacy and safety of BPA in a consecutive group of patients who were diagnosed and treated in the national referral center for CTEPH in the Czech Republic. Here we report data from 160 BPA procedures performed in 64 patients. Efficacy analysis was performed in the subgroup of 25 patients who completed BPA series. Significant improvements were observed in New York Heart Association functional class (4% to 79% in I/II, p < 0.001), 6 min walking test distance (+54.3 m, p < 0.001), risk profile (15.8% to 68.5% with presence of 2/3 low risk criteria, p < 0.001), pulmonary artery mean pressure (−18%, p < 0.001), pulmonary vascular resistance (−32%, p < 0.001), stroke volume (+17%, p = 0.011) and quality of life (+37% in assessment of overall health status by a patient, p < 0.001). We observed 1 fatal periprocedural complication (1.6% of all 64 patients) and 19 BPA-related non-fatal complications (11.9% of all 160 interventions) that predominantly included hemoptysis (10.0% of all sessions). Overall survival at 12 months was 94.6%.
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Papadopoulou V, Karyofyllis P, Tsiapras D, Demerouti E, Kosmas I, Voudris V. Systematic Review: Does Balloon Pulmonary Angioplasty (BPA) Improve Right Ventricular Function in CTEPH Patients? Evaluation Based on Imaging Findings. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00839-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Abstract
PURPOSE OF REVIEW The present review provides an update on treatment of chronic thromboembolic pulmonary hypertension (CTEPH), a rare form of pulmonary hypertension characterized by precapillary pulmonary hemodynamic parameters with chronic thrombotic occlusion of the pulmonary vasculature. RECENT FINDINGS Pulmonary thromboendarectomy (PTE) remains the recommended treatment for patients with surgically accessible disease. Recent data suggest that patients preoperatively bridged with medical therapy may have improved outcomes but further research is needed. Riociguat improves hemodynamics, right ventricular function, quality of life, and functional capacity and is the drug of choice for patients with inoperable/persistent disease. Recently published data suggest that endothelin receptor blockers and treprostinil may also have a role in medical management of this patient population. A growing body of evidence indicates that in experienced centers balloon pulmonary angioplasty (BPA) may be a well tolerated and effective adjunct to pharmacological treatment for patients with inoperable disease affecting subsegmental vasculature. SUMMARY Untreated CTEPH carries significant morbidity and mortality. Recent publications provide a wealth of data on safety and efficacy of BPA for inoperable subsegmental disease, but its precise fit in the treatment algorithm, both pharmacological and procedural, requires further investigation. PTE remains the procedure of choice for surgically accessible disease.
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Karyofyllis P, Demerouti E, Papadopoulou V, Voudris V, Matsubara H. Balloon Pulmonary Angioplasty as a Treatment in Chronic Thromboembolic Pulmonary Hypertension: Past, Present, and Future. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020; 22:7. [DOI: 10.1007/s11936-020-0807-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
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