Comparative outcomes of pulmonary endarterectomy, balloon pulmonary angioplasty and sGC stimulator therapy in chronic thromboembolic pulmonary hypertension
T Kramer, M Foerster, M Hellmich, M KramerAbstract
Background/Introduction
Chronic thromboembolic pulmonary hypertension (CTEPH) can be treated with pulmonary endarterectomy (PEA), balloon pulmonary angioplasty (BPA), medical therapy, or a combination. While lesion localisation and patient characteristics guide treatment selection, the comparative impact of these strategies on clinical outcomes and risk status remains insufficiently defined.
Purpose
To compare the efficacy, safety and impact on risk status of PEA, BPA and sGC stimulator monotherapy in patients with CTEPH during 18 months of follow-up.
Methods
This retrospective multicentre study analysed patients with confirmed CTEPH treated with PEA, BPA or sGC stimulator monotherapy, with baseline and follow-up data collected from two expert centres over 18 months. Diagnosis was established by right heart catheterisation, ventilation/perfusion scanning and pulmonary angiography. Changes in clinical parameters, outcomes and risk status were assessed at baseline and follow-up using risk stratification approaches adapted from pulmonary arterial hypertension.
Results
Between September 2010 and January 2021, 74 patients were included: 26 (35.1%) underwent PEA, 15 (20.3%) BPA and 33 (44.6%) received sGC stimulator monotherapy. At repeat right heart catheterisation, pulmonary vascular resistance improved most after PEA (9.8 ± 6.5 to 3.9 ± 2.0 Wood units), followed by BPA (10.1 ± 3.5 to 5.4 ± 3.3 Wood units) and sGC stimulator therapy (12.8 ± 5.6 to 9.9 ± 4.9 Wood units) (all p < 0.05). Improvements in six-minute walk distance, NT-proBNP, echocardiographic parameters, World Health Organization functional class and risk status were greatest with PEA, followed by BPA and sGC stimulator therapy.
Conclusions
PEA remains the most effective treatment for CTEPH when performed in experienced centres. BPA is generally safe and effective but yields smaller improvements compared with PEA. sGC stimulator monotherapy provides modest haemodynamic and functional benefits with a favourable safety profile. Risk stratification approaches adapted from pulmonary arterial hypertension may be applicable to CTEPH, although further validation is required. Long-term outcomes of BPA and sequential combination strategies warrant further investigation.