Sex Differences in Chronic Thromboembolic Pulmonary Hypertension. Treatment Options over Time in a National Referral Center

Sex-Specific Differences in Chronic Thromboembolic Pulmonary Hypertension Treated with Balloon Pulmonary Angioplasty

Background/Objectives: Several studies describe the sex-specific differences in cardiovascular diseases. However, there is still limited research reporting the difference between men and women with chronic thromboembolic pulmonary hypertension (CTEPH) treated with balloon pulmonary angioplasty (BPA). The aim of this study was to evaluate sex-specific differences in patients with CTEPH treated with BPA. Methods: This retrospective study included CTEPH patients treated with BPA. The patients' hemodynamic and clinical parameters were assessed at baseline and 3 months after completion of BPA treatment. Results: This study included 94 patients (44 women, 46.8%). At baseline, women had higher systolic pulmonary arterial pressure (sPAP) (76 ± 18.5 vs. 85 ± 17.6 mmHg; p = 0.03) and pulmonary vascular resistance (8.21 [5.55-10.17] vs. 9.89 [6.31-14.06] Wood Units; p = 0.03) compared to men. There were no differences in clinical characteristics between the sexes. At follow-up, women had lower sPAP (49 [41-54] vs. 43 [37-49] mmHg; p = 0.04) and pulmonary capillary wedge pressure (10 [9-14] vs. 9 [8-11] mmHg; p = 0.03), but a higher cardiac index (2.57 ± 0.53 vs. 2.82 ± 0.50 L/min/m2; p = 0.03), as well as better Dyspnea Borg Scale outcomes, compared to men. Women had a greater reduction in mean pulmonary artery pressure (-43% vs. -37%; p = 0.049) than men. Conclusions: At baseline, women with CTEPH had worse hemodynamic parameters than men despite similar clinical symptoms. However, the hemodynamic status of women was better after BPA therapy. Hence, women seem better adapted to the disease at baseline and respond better to BPA. Further data are needed to investigate whether the management of CTEPH patients should be sex-differentiated.

Computed tomography identifies sex-specific differences in surgical chronic thromboembolic pulmonary hypertension

Background

Registry data suggest women are less likely than men to undergo pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension despite a similar proportion of proximal vs distal disease. We hypothesized that sex-specific differences could be elicited with a computed tomography pulmonary angiography analysis beyond proximal vs distal.

Methods

Preoperative computed tomography pulmonary angiography of patients who underwent pulmonary thromboendarterectomy for chronic thromboembolic pulmonary hypertension from January 2017 to September 2021 was analyzed. The pulmonary vascular tree was divided into 32 named vessels with chronic thromboembolism presence and lesion type recorded for each vessel. If no lesion was identified in a segmental vessel, subsegmental disease was recorded when present.

Results

One hundred forty-four patients (mean age 57 ± 15 years, 78 women) were included. There were no sex differences in baseline hemodynamics. Men had more vessels involved than women (mean 20.3 vs 17.1, p = 0.004) and had fewer disease-free pulmonary segments (mean 4.9 ± 4.3 vs 7.6 ± 5.5, p = 0.001). Men had a greater number of webs, eccentric thickening, and occlusions. The distribution of lesion type did not significantly differ between sexes at the main or lobar level but men had significantly more lesions in the segmental vasculature while women had a higher proportion of subsegmental lesions (p < 0.001).

Conclusions

Sex-specific differences in chronic thromboembolic pulmonary hypertension are demonstrated on computed tomography pulmonary angiography in overall distribution and lesion type at the segmental and subsegmental level with women having fewer and more distal lesions despite similar hemodynamics.

Chronic thromboembolic pulmonary hypertension treatment and sex: Systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

Chronic thromboembolic pulmonary hypertension (CTEPH) is a complication of pulmonary embolism and a major cause of chronic pulmonary hypertension leading to right heart failure and death. While pulmonary endarterectomy is the treatment of choice, some patients might benefit from medical therapy or balloon pulmonary angioplasty. Sex differences in outcomes of these therapies are not well characterized.

MATERIAL AND METHODS

We conducted a systematic review and meta-analysis to investigate sex differences in outcomes of various therapies for CTEPH. We searched MEDLINE, PubMed, Embase, CINAHL and the Cochrane Library databases between January 1, 2010 and April 30, 2021, published in English. We pooled incidence estimates using random-effects meta-analyses. We evaluated heterogeneity using the I2 statistic. We assessed publication bias using Begg's and Egger's tests. This study is registered in PROSPERO, CRD42021268504.

RESULTS

A total of 19 studies met the eligibility criteria, but only 3 trials provided separate outcomes for women and men. Two studies evaluated the efficacy of BPA, and one study evaluated the efficacy of riociguat (129 patients). Overall, 57.3% of patients were women and 62.6% were in functional class III. Mean time of follow-up was 55.5 (SD 26.1) weeks. Women showed a significantly better response in cardiac index (mean difference [MD], 0.10L/min/m2; 95% confidence interval [CI], 0.04-0.16; I2=0%; P=0.001). Alternatively, the reduction of pulmonary vascular resistances was significantly higher for men than for women (MD, 161.17dynscm-5; 95% CI, 67.99-254.35; I2=0%; P=0.0007).

CONCLUSIONS

Women and men might show different hemodynamic responses to riociguat or BPA for CTEPH.

Sex differences in Chronic Thromboembolic Pulmonary Hypertension

Chronic thromboembolic pulmonary hypertension (CTEPH) is an underdiagnosed sequela of acute pulmonary embolism with varied clinical presentation causing significant morbidity among the affected population. There exist important differences in the occurrence, clinical features and diagnosis of CTEPH between men and women, with women carrying a greater predisposition for the disease. Ongoing studies have also pointed out variations among men and women, in the treatment offered and long-term outcomes including mortality. This focused review article highlights important sex-associated differences in multiple aspects of CTEPH including its epidemiology, clinical features, diagnosis, treatment and outcomes as reported in current literature and highlights the need for future research to facilitate a clearer understanding of these differences.

Outcomes of Chronic Thromboembolic Pulmonary Hypertension After Balloon Pulmonary Angioplasty and Pulmonary Endarterectomy

Background

The contemporary outcome of balloon pulmonary angioplasty (BPA) and pulmonary endarterectomy (PEA) in patients with chronic thromboembolic pulmonary hypertension (CTEPH) are unclear.

Objectives

This study aimed to clarify the characteristics and outcomes of CTEPH patients treated with BPA and PEA in Japan.

Methods

Among 1,270 participants enrolled between 2018 and 2023 in the CTEPH AC (Chronic Thromboembolic Pulmonary Hypertension Anticoagulant) registry, a Japanese nationwide CTEPH registry, 369 treatment-naive patients (BPA strategy: n = 313; PEA strategy: n = 56) and 690 on-treatment patients (BPA strategy: n = 561; PEA strategy: n = 129) were classified according to the presence of prior reperfusion therapy. Morbidity and mortality events (all-cause death, rescue mechanical reperfusion therapy, and/or initiation of parenteral pulmonary vasodilators), pulmonary hemodynamics, exercise tolerance, and relevant laboratory test results were evaluated.

Results

The BPA strategy was chosen in older patients than the PEA strategy (mean age, BPA vs PEA: 66.5 ± 12.6 years vs 62.5 ± 11.8 years; P = 0.028). Median follow-up period was 615 (Q1-Q3: 311-997) days in treatment-naive patients and 1,136 (Q1-Q3: 684-1,300) days in on-treatment patients. BPA strategy had as acceptable morbidity and mortality as PEA strategy (5-year morbidity and mortality event rate, BPA vs PEA: 10.2% [95% CI: 5.2%-19.5%] vs 16.1% [95% CI: 4.3%-50.6%] in treatment-naive patients; 9.7% [95% CI: 6.7%-13.8%] vs 6.9% [95% CI: 2.7%-17.3%] in on-treatment patients), with greater improvement of renal function; glomerular filtration rate in propensity score-matched population (difference between change: 4.9 [95% CI: 0.5-9.3] mL/min/1.73 m2; P = 0.030).

Conclusions

BPA strategy was more frequently chosen in older patients compared with PEA strategy and showed acceptable outcomes for efficacy with greater advantage for improvement in renal function. (Multicenter registry of chronic thromboembolic pulmonary hypertension in Japan; UMIN000033784).

Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension: a clinical consensus statement of the ESC working group on pulmonary circulation and right ventricular function

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.

Balloon pulmonary angioplasty can be an effective and safe therapeutic option in non-surgical elderly patients

Background

Advanced age, frailty, and age-related comorbidities are the major causes of pulmonary endarterectomy disqualification in patients with chronic thromboembolic pulmonary hypertension (CTEPH). Balloon pulmonary angioplasty (BPA) is an attractive and less invasive therapy for elderly patients. However, information about the safety, procedure tolerance, and effectiveness of BPA in elderly patients is limited.

Objective and methods

We aimed to analyze the safety, tolerance, and efficacy of BPA in CTEPH patients aged ≥70 years. This observational, descriptive, and retrospective series included consecutive patients aged ≥70 years, who underwent completed or interrupted BPA programs at a pulmonary hypertension reference center between May 2013 and May 2022.

Results

We enrolled 155 patients in our institution's BPA program. Among these, 33 patients were aged ≥70 years (mean age, 76.4 years; women, 75.8%) and had finished or interrupted BPA programs. In this cohort, we performed 116 BPA procedures (average, 3.6 ± 1.8 sessions/patient). Among the 33 patients, 19 (57.6%) completed treatment for all lobes, while the BPA program was interrupted in the remaining 14 (42.4%). Among all 33 patients, BPA was associated with a significant reduction in mean pulmonary arterial pressure (39.2 ± 9.3 vs. 32.8 ± 8.8 mmHg; p < 0.001) and pulmonary vascular resistance (6.7 ± 3.1 vs. 4.4 ± 2.0 WU; p < 0.001), along with an improvement in the cardiac index (2.5 ± 0.6 vs. 2.8 ± 0.7 L/min/m²; p = 0.04) with significant reductions in the N-terminal prohormone of brain natriuretic peptide level (pre-BPA, 353 pg/mL [207–1,960 pg/mL] vs. post-BPA, 167 pg/mL [73–629 pg/mL]; p = 0.03). The patients' functional class improved, and pulmonary hypertension-targeting drug requirements were significantly reduced. The pulmonary injury appeared in 3.4% of the 116 procedures, of which 50% were of grade 2. No patient of ≥70 years had grade 5 pulmonary injury. One periprocedural mortality was recorded (3%), and the median follow-up period was 2.8 years. The survival rate of the entire cohort at 1 and 3 years was 90.5 and 82.8%, respectively.

Conclusion

BPA is an effective and safe approach in patients aged ≥70 years. It significantly improves patients' functional class, hemodynamic, and biomarkers, and reduces their pulmonary hypertension-targeting medical therapy requirements. These successes were achieved even though a significant percentage of patients did not complete the therapy. The rates of procedural complications and periprocedural mortality were low. Survival at 1 and 3 years was good in comparison to that of younger patients undergoing BPA.

Pulmonary Hypertension: Current Diagnosis, Approach and Treatment at the Dawn of the New European Guidelines

A turning point in the field of pulmonary hypertension (PH) is the most recent publication of the new European Guidelines for the diagnosis and treatment of pulmonary hypertension, a collaboration between the European Society of Cardiology and the European Respiratory Society [...].