Refined balloon pulmonary angioplasty for inoperable patients with chronic thromboembolic pulmonary hypertension.

Although balloon pulmonary angioplasty (BPA) for inoperable patients with chronic thromboembolic pulmonary hypertension was first reported over a decade ago, its clinical application has been restricted because of limited efficacy and complications. We have refined the procedure of BPA to maximize its clinical efficacy. Sixty-eight consecutive patients with inoperable chronic thromboembolic pulmonary hypertension underwent BPA. We evaluated pulmonary artery diameters and determined the appropriate balloon size by using intravascular ultrasound. We performed BPA in a staged fashion over multiple, separate procedures to maximize efficacy and reduce the risk of reperfusion pulmonary injury. A total of 4 (2-8) sessions were performed in each patient, and the number of vessels dilated per session was 3 (1-14). The World Health Organization functional class improved from 3 to 2 (P<0.01), and mean pulmonary arterial pressure was decreased from 45.4 ± 9.6 to 24.0 ± 6.4 mm Hg (P<0.01). One patient died because of right heart failure 28 days after BPA. During follow-up for 2.2 ± 1.4 years after the final BPA, another patient died of pneumonia, and the remaining 66 patients are alive. In 57 patients who underwent right heart catheterization at follow-up, improvement of mean pulmonary arterial pressure was maintained (24.0 ± 5.8 mm Hg at 1.0 ± 0.9 years). Forty-one patients (60%) developed reperfusion pulmonary injury after BPA, but mechanical ventilation was required in only 4 patients. Our refined BPA procedure improves clinical status and hemodynamics of inoperable patients with chronic thromboembolic pulmonary hypertension, with a low mortality. A refined BPA procedure could be considered as a therapeutic approach for patients with inoperable chronic thromboembolic pulmonary hypertension.