Additional percutaneous transluminal pulmonary angioplasty for residual or recurrent pulmonary hypertension after pulmonary endarterectomy

Abstract

Background

Pulmonary endarterectomy (PEA) has been the most effective therapy for chronic thromboembolic pulmonary hypertension (CTEPH). However, residual or recurrent pulmonary hypertension often persists after PEA. Recently, catheter-based angioplasty, called percutaneous transluminal pulmonary angioplasty (PTPA) or balloon pulmonary angioplasty, has been developed as a promising strategy for CTEPH. Therefore, the usefulness of PTPA for residual or recurrent pulmonary hypertension after PEA was investigated.

Methods

Thirty-nine patients underwent PEA from January 2000, and a total of 423 consecutive PTPA sessions in 110 patients were performed from January 2009 to May 2014. Of them, 9 patients (23.0% of 39 patients undergoing PEA and 8.2% of 110 patients undergoing PTPA) had undergone previous PEA and additional PTPA.

Results

In these 9 patients, pulmonary vascular resistance (PVR) was 15.6 (7.8–18.9) wood units at baseline, and significantly improved after PEA [5.6 (3.5–6.5) wood units] (p < 0.05). However, PVR gradually deteriorated before PTPA [8.1 (6.1–12.3) wood units] compared to after PEA, suggesting that these 9 patients had residual or recurrent pulmonary hypertension after PEA. PTPA was performed at 4.1 (2.7–7.9) years after PEA. Follow-up catheterization at 1.9 (1.3–3.3) years after PTPA revealed significant improvement of PVR [4.2 (2.8–4.8) wood units] (p < 0.05).

Conclusions

A hybrid approach combining PEA and additional PTPA may be reasonable for patients with both proximal and very distal lesions not easily approachable by PEA. PTPA could be a promising alternative therapeutic strategy for residual or recurrent pulmonary hypertension after PEA.

Introduction

Chronic thromboembolic pulmonary hypertension (CTEPH) treated with conventional medical therapy, such as ambulatory oxygen therapy and anticoagulation, carries a poor prognosis [1], [2], [3], [4], [5], [6]. Pulmonary artery vasodilators for pulmonary arterial hypertension, such as prostanoids, phosphodiesterase-5 inhibitors, endothelin receptor antagonists, and stimulators of guanylate cyclase, are palliative [2], [7], [8], [9]. Pulmonary endarterectomy (PEA) is the only curative strategy with long-term results for CTEPH. Therefore, PEA is established as a first-line treatment for many patients with CTEPH [2], [10]. Meanwhile, some patients suffer residual pulmonary hypertension after PEA [10], [11], [12]. Residual pulmonary hypertension adversely impacts on quality of life and outcome in many patients. Nevertheless, a therapeutic strategy for residual pulmonary hypertension has not been well established [10], [11], [12].

Percutaneous transluminal pulmonary angioplasty (PTPA) has attracted attention as a new, less invasive intervention for patients with CTEPH because it is highly efficacious in relieving symptoms and improving cardiopulmonary hemodynamics [13], [14], [15], [16], [17], [18], [19], [20], [21], [22], [23]. Until recently, there have been crucial concerns about reperfusion pulmonary edema in PTPA, but refinement and innovation of PTPA techniques using a specific scoring index, PEPSI, and pressure wire have overcome reperfusion pulmonary edema and pulmonary injury [14], [17]. Additionally, there is a high risk associated with re-sternotomy when patients undergo PEA again. Therefore, it is expected that PTPA is suitable for residual pulmonary hypertension after PEA.

The purposes of this study were: 1) to investigate the clinical characteristics of patients with residual pulmonary hypertension after PEA, and 2) to clarify the efficacy and safety of PTPA in terms of clinical and hemodynamic improvement in patients with residual pulmonary hypertension after PEA. If this approach proves to be effective, PTPA will restructure the current therapeutic strategy for residual pulmonary hypertension after PEA.