The combination of pulmonary endarterectomy (PEA), a surgery to remove blood clots in the lungs, and balloon pulmonary angioplasty (BPA), the use of balloons to open narrowed or blocked blood vessels — could improve outcomes for people with chronic thromboembolic pulmonary hypertension (CTEPH), researchers reported.
Treatment, including the use of BPA alone, was also seen to “translate into excellent survival in not only operable CTEPH but also non-operable CTEPH” patients, they wrote.
The study, “The role of balloon pulmonary angioplasty and pulmonary endarterectomy: Is chronic thromboembolic pulmonary hypertension still a life-threatening disease?” was published in the International Journal of Cardiology.
CTEPH is a rare form of pulmonary hypertension caused by clots that obstruct the lung’s blood vessels. PEA surgery is generally considered the gold standard for CTEPH treatment.
In recent years, BPA has emerged as a non-surgical option for CTEPH treatment. But the role of this relatively new treatment approach in optimal CTEPH care is still being evaluated.
“We aimed to clarify the long-term outcomes in patients with CTEPH in the modern management era from experience at Kobe University,” the researchers wrote.
Using data from Kobe University Hospital, researchers in Japan identified people diagnosed with CTEPH after 2011, when BPA first became available. In total, 143 CTEPH patients diagnosed from January 2011 to December 2019 were analyzed; of these, 47 patients were eligible for PEA surgery (operable CTEPH).
In total, 41 people underwent PEA, 90 underwent BPA (but not PEA), and 12 went without an interventional treatment.
Among the PEA patient group, 25 also underwent BPA, including 22 people who opted for BPA after the surgery to help with residual disease or its symptoms.
Relative to those without any intervention, patients who received surgery were significantly younger on average (58.9 vs. 68.4 years), more likely to be male (39.0% vs. 17.6%), and to have a more frequent history of acute pulmonary embolism (blockage in a pulmonary artery; 46.3% vs. 26.5%). Operated patients generally also had more severe hemodynamics (blood pressure-related measurements) before treatment.
Using statistical models, the researchers compared outcomes among patients given different treatments.
Analyses of hemodynamic parameters suggested that PEA and BPA — used separately, and in combination — changed hemodynamic parameters to close to normal levels for most patients.
“Almost normal hemodynamics could be achieved after these interventional treatments, and these hemodynamic improvements translate into excellent survival … Additionally, combination therapy with PEA and BPA could improve hemodynamics dramatically, even though baseline hemodynamics were severe,” the researchers wrote.
At a median follow-up of 40.4 months, 14 out of 143 patients (9.8%) had died.
The one- and five-year survival rates among patients given PEA alone were 92.9% and 74.5%, respectively. Among those who received BPA alone, survival rates at one year were 97.6%, and 90.1% at five years. In patients not given either procedure, the one- and five-year survival rates were 96.9% and 86.9%.
No deaths were recorded among the 25 people who underwent both PEA and BPA.
“Our study demonstrated that combination approach with PEA and BPA could achieve dramatical improvements of hemodynamics and symptoms with no deaths,” the researchers concluded. “BPA and PEA appear to be mutually complementary therapies for CTEPH patients.”
Moreover, their work “indicated that almost all patients with CTEPH could be mechanically treated with either PEA or BPA in a CTEPH expert center, which would lead to a notable improvement in their prognosis,” they added.
The most common cause of death among these people was a malignant cancer found during follow-up and not right heart failure, which has a well-established connection to pulmonary hypertension.
“CTEPH patients rarely die from right heart failure in the recent management era, however careful screening and follow-up might be required for early diagnosis of cancer,” the researchers wrote. “More work is still needed to better understand the relation between CTEPH and malignant cancer.”
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