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Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension.

Kurzyna M, Darocha S, Koteja A, Pietura R, Torbicki A - Postepy Kardiol Interwencyjnej (2015)

View Article: PubMed Central - PubMed

Affiliation: Department of Pulmonary Circulation and Thromboembolic Diseases, Medical Centre of Postgraduate Education, European Health Centre Otwock, Otwock, Poland.

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Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare but potentially life-threatening disease of the pulmonary circulation... The most accepted scenario is that of aborted recanalisation of pulmonary arteries after a thromboembolic episode... Usually, individual cardiac surgeons are responsible for PEA in their centres, as the learning curve for this intervention has been well documented... With growing experience of clinicians, radiologists, surgeons, and anaesthesiologists, an increasing proportion of patients with CTEPH may benefit from PEA despite distal, less accessible intravascular residua and/or advanced age and comorbidities... Until now, the experience of our team includes 37 BPA procedures, which consisted of angioplasty of 105 vessels in 20 patients with CTEPH... All patients who underwent BPA because of distal lesion localisation survived... In technical terms, BPA does not significantly differ from balloon angioplasty performed in other vessels (Figure 2)... It is not recommended that BPA procedures be performed by cardiologists or interventional radiologists who have experience in other vascular regions but no experience in interventions within the pulmonary circulation... During one procedure, no more than two segmental arteries or their subsegmental equivalents should be dilated due to the risk of reperfusion oedema... Reperfusion oedema results from redistribution of blood flow to areas supplied by dilated vessels, in which vascular resistance has abruptly decreased... However, selection of patients for the procedure will not be a binary choice between a risky but potentially curative surgery and moderately or poorly effective pharmacotherapy alone... Balloon angioplasty, currently recommended in patients who do not qualify for PEA, will become an increasingly common treatment option in the future... The order of the procedures performed would remain an open question... From our preliminary experience, it may be concluded that BPA in vessels with the removed media is more difficult to perform and is associated with a higher risk of complications... In conclusion, BPA procedures and modern pharmacotherapy with drugs used in PAH so far will play an increasingly significant role in the treatment of patients with CTEPH.

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Survival curves for patients with CTEPH treated with PEA (shadow line) and who were treated by pharmacotherapy only (solid line) – reprinted from Wieteska et al. [6]
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Figure 0001: Survival curves for patients with CTEPH treated with PEA (shadow line) and who were treated by pharmacotherapy only (solid line) – reprinted from Wieteska et al. [6]

Mentions: Management of CTEPH requires precise differential diagnosis and qualification for surgical treatment by an experienced multidisciplinary team. Indeed, in operable patients pulmonary endarterectomy (PEA) is highly effective in restoring functional status and improving life expectancy. A surgical technique has been optimised and implemented worldwide by a group from San Diego – University of California [4]. Nevertheless, PEA performed in deep hypothermia and intermittent total cardiac arrest remains one of the most demanding cardiovascular interventions and is performed only in a limited number of highly dedicated centres. As an example, Papworth Hospital is the only centre performing PEA in the UK, while Marie-Lannelongue Hospital in Paris remains a referral centre for France for this type of surgery. Usually, individual cardiac surgeons are responsible for PEA in their centres, as the learning curve for this intervention has been well documented [5]. With growing experience of clinicians, radiologists, surgeons, and anaesthesiologists, an increasing proportion of patients with CTEPH may benefit from PEA despite distal, less accessible intravascular residua and/or advanced age and comorbidities. This is of paramount importance since the outcome of non-operated patients is drastically worse (Figure 1), despite identical baseline haemodynamic characteristicsand significant perioperative mortality of 2–10% in patients submitted to PEA [6]. Nevertheless, even in the leading CTEPH referral centres almost 50% patients remain on medical treatment alone, with grim perspectives regarding life quality and expectancy. Based on a large randomised trial and promising long-term effects on exercise tolerance [7, 8] direct guanylyl cyclase stimulator (riociguat) has been approved for treatment of inoperable CTEPH. Riociguat may protect patent pulmonary arterioles from progressive remodelling [9] but is unlikely to affect the culprit post-embolic residua. Recently, balloon pulmonary angioplasty (BPA) has emerged as a promising new interventional option in non-operable CTEPH. In 2001, Feinstein et al. from Harvard Medical School described a group of 18 CTEPH patients treated with BPA [10]. Of these, 16 were excluded from PEA due to distal lesions, and two due to the presence of comorbidities increasing the risk associated with surgical treatment. In total, 47 procedures were performed, thus dilating or restoring the patency of 107 arteries. In the periprocedural period, 1 patient died of reperfusion pulmonary oedema and right ventricular failure. In total, reperfusion oedema occurred in 23% of cases, and its presence correlated with the value of pulmonary artery pressure (PAP) prior to the procedure. Long-term follow-up (mean, 34 months) showed an increase in physical capacity, manifesting itself as an improvement in NYHA class from a mean value of 3.3 prior to the procedure to a mean value of 1.8 following the procedure.


Balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension.

Kurzyna M, Darocha S, Koteja A, Pietura R, Torbicki A - Postepy Kardiol Interwencyjnej (2015)

Survival curves for patients with CTEPH treated with PEA (shadow line) and who were treated by pharmacotherapy only (solid line) – reprinted from Wieteska et al. [6]
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4372623&req=5

Figure 0001: Survival curves for patients with CTEPH treated with PEA (shadow line) and who were treated by pharmacotherapy only (solid line) – reprinted from Wieteska et al. [6]
Mentions: Management of CTEPH requires precise differential diagnosis and qualification for surgical treatment by an experienced multidisciplinary team. Indeed, in operable patients pulmonary endarterectomy (PEA) is highly effective in restoring functional status and improving life expectancy. A surgical technique has been optimised and implemented worldwide by a group from San Diego – University of California [4]. Nevertheless, PEA performed in deep hypothermia and intermittent total cardiac arrest remains one of the most demanding cardiovascular interventions and is performed only in a limited number of highly dedicated centres. As an example, Papworth Hospital is the only centre performing PEA in the UK, while Marie-Lannelongue Hospital in Paris remains a referral centre for France for this type of surgery. Usually, individual cardiac surgeons are responsible for PEA in their centres, as the learning curve for this intervention has been well documented [5]. With growing experience of clinicians, radiologists, surgeons, and anaesthesiologists, an increasing proportion of patients with CTEPH may benefit from PEA despite distal, less accessible intravascular residua and/or advanced age and comorbidities. This is of paramount importance since the outcome of non-operated patients is drastically worse (Figure 1), despite identical baseline haemodynamic characteristicsand significant perioperative mortality of 2–10% in patients submitted to PEA [6]. Nevertheless, even in the leading CTEPH referral centres almost 50% patients remain on medical treatment alone, with grim perspectives regarding life quality and expectancy. Based on a large randomised trial and promising long-term effects on exercise tolerance [7, 8] direct guanylyl cyclase stimulator (riociguat) has been approved for treatment of inoperable CTEPH. Riociguat may protect patent pulmonary arterioles from progressive remodelling [9] but is unlikely to affect the culprit post-embolic residua. Recently, balloon pulmonary angioplasty (BPA) has emerged as a promising new interventional option in non-operable CTEPH. In 2001, Feinstein et al. from Harvard Medical School described a group of 18 CTEPH patients treated with BPA [10]. Of these, 16 were excluded from PEA due to distal lesions, and two due to the presence of comorbidities increasing the risk associated with surgical treatment. In total, 47 procedures were performed, thus dilating or restoring the patency of 107 arteries. In the periprocedural period, 1 patient died of reperfusion pulmonary oedema and right ventricular failure. In total, reperfusion oedema occurred in 23% of cases, and its presence correlated with the value of pulmonary artery pressure (PAP) prior to the procedure. Long-term follow-up (mean, 34 months) showed an increase in physical capacity, manifesting itself as an improvement in NYHA class from a mean value of 3.3 prior to the procedure to a mean value of 1.8 following the procedure.

View Article: PubMed Central - PubMed

Affiliation: Department of Pulmonary Circulation and Thromboembolic Diseases, Medical Centre of Postgraduate Education, European Health Centre Otwock, Otwock, Poland.

AUTOMATICALLY GENERATED EXCERPT
Please rate it.

Chronic thromboembolic pulmonary hypertension (CTEPH) is a rare but potentially life-threatening disease of the pulmonary circulation... The most accepted scenario is that of aborted recanalisation of pulmonary arteries after a thromboembolic episode... Usually, individual cardiac surgeons are responsible for PEA in their centres, as the learning curve for this intervention has been well documented... With growing experience of clinicians, radiologists, surgeons, and anaesthesiologists, an increasing proportion of patients with CTEPH may benefit from PEA despite distal, less accessible intravascular residua and/or advanced age and comorbidities... Until now, the experience of our team includes 37 BPA procedures, which consisted of angioplasty of 105 vessels in 20 patients with CTEPH... All patients who underwent BPA because of distal lesion localisation survived... In technical terms, BPA does not significantly differ from balloon angioplasty performed in other vessels (Figure 2)... It is not recommended that BPA procedures be performed by cardiologists or interventional radiologists who have experience in other vascular regions but no experience in interventions within the pulmonary circulation... During one procedure, no more than two segmental arteries or their subsegmental equivalents should be dilated due to the risk of reperfusion oedema... Reperfusion oedema results from redistribution of blood flow to areas supplied by dilated vessels, in which vascular resistance has abruptly decreased... However, selection of patients for the procedure will not be a binary choice between a risky but potentially curative surgery and moderately or poorly effective pharmacotherapy alone... Balloon angioplasty, currently recommended in patients who do not qualify for PEA, will become an increasingly common treatment option in the future... The order of the procedures performed would remain an open question... From our preliminary experience, it may be concluded that BPA in vessels with the removed media is more difficult to perform and is associated with a higher risk of complications... In conclusion, BPA procedures and modern pharmacotherapy with drugs used in PAH so far will play an increasingly significant role in the treatment of patients with CTEPH.

No MeSH data available.