The results of the balloon pulmonary angioplasty program in chronic thromboembolic pulmonary hypertension patients in a national and European reference center resemble those of Japanese series
Authors: Velazquez Martin M T , Albarran A , Sarnago F , Maneiro N M , Huertas S , Olazabal A , Cristo Ropero M J , Cruz Utrilla A , Perez Olivares C , Segura De La Cal T , Alonso Charterina S , Revilla Ostolaza Y , Ruiz Curiel A , Otero Escudero M , Escribano Subias P 
Published: October 2021

Abstract

Introduction
Balloon pulmonary angioplasty (BPA) is an established technique in patients with non-operable chronic thromboembolic pulmonary hypertension (CTEPH). It improves hemodynamics, functional class, biomarkers and survival, with current periprocedural mortality rates below 1–2% in experienced centers. However, there is a discrepancy between the magnitude of European or American series' results and those of Japanese centers, with a pulmonary vascular resistance reduction of 26–43% in the former and 45–65% in the latter.

Purpose
To present the results of the BPA program of a CTEPH national and European reference center and to compare them with the results of Japanese series.

Methods
We analyze the improvement in hemodynamics, functional parameters, biomarkers and pulmonary vasodilators requirements of patients with a finished BPA program. Besides, we show safety and survival of the whole cohort of patients undergoing BPA between May 2013 and December 2020 in a CTEPH national and European reference center.

Results
We performed 503 BPA sessions in 120 patients, 64% women, mean age 61±15 years (19–84). The reasons for BPA were: distal involvement in 105 patients, comorbidities in 3 patients, personal preferences in 3 patients and residual pulmonary hypertension after pulmonary thromboendarterectomy in 9 patients. Mean follow-up from therapy beginning was 50±16 months (22–92). One patient died 7 days after her first BPA due to severe lung injury (peri-procedural mortality 0.83%). BPA therapy was interrupted in 5 patients (4 octogenarians with poor tolerance to procedures or little clinical improvement and 1 patient with relapsing severe hemoptysis during BPA sessions). Seventy three of the 114 remaining patients had finished their BPA program. The table shows the hemodynamic, biomarker and functional class improvement and the decrease in pulmonary vasodilators requirements of patients with complete BPA therapy. During follow-up 2 patients died: one due to hemoptysis related to pneumonia, 23 months after his first BPA, with BPA program already completed; the other due to leukemia, while in active BPA program. Thus, survival of our BPA series at 7 years follow-up is 98.2%.

Conclusions
The efficacy, safety and survival results of BPA therapy in patients with inoperable CTEPH at a national and European reference CTEPH center are comparable to those of Japanese series. Furthermore, hemodynamic and functional improvement and the reduction of specific medication requirements, along with therapy safety, position BPA as the first choice therapeutic option in patients not subsidiary of surgery.

Funding Acknowledgement
Type of funding sources: Public hospital(s). Main funding source(s): University Hospital 12 de Octubre, Madrid, Spain Changes after complete BPA therapySurvival from the initial BPA procedure