A new era of therapeutic strategies for chronic thromboembolic pulmonary hypertension by two different interventional therapies; pulmonary endarterectomy and percutaneous transluminal pulmonary angioplasty

Abstract

Background: Pulmonary endarterectomy (PEA) is established for the treatment of chronic thromboembolic pulmonary hypertension (CTEPH). Recently, percutaneous transluminal pulmonary angioplasty (PTPA) has been added for peripheral-type CTEPH, whose lesions exist in segmental, subsegmental, and more distal pulmonary arteries. A shift in clinical practice of interventional therapies occurred in 2009 (first mainly PEA, later PTPA). We examined the latest clinical outcomes of patients with CTEPH.

Methods and results: This study retrospectively included 136 patients with CTEPH. Twenty-nine were treated only with drug (Drug-group), and the other 107 underwent interventional therapies (Interventions-group) (39 underwent PEA [PEA-group] and 68 underwent PTPA [PTPA-group]). Total 213 PTPA sessions (failures, 0%; mortality rate, 1.47%) was performed in the PTPA-group (complications: reperfusion pulmonary edema, 7.0%; hemosputum or hemoptysis, 5.6%; vessel dissection, 2.3%; wiring perforation, 0.9%). Although baseline hemodynamic parameters were significantly more severe in the Interventions-group, the outcome after the diagnosis was much better in the Interventions-group than in the Drug-group (98% vs. 64% 5-year survival, p<0.0001). Hemodynamic improvement in the PEA-group was a 46% decrease in mean pulmonary arterial pressure (PAP) and a 49% decrease in total pulmonary resistance (TPR) (follow-up period; 74.7 ± 32.3 months), while those in the PTPA-group were a 40% decrease in mean PAP and a 49% decrease in TPR (follow-up period; 17.4 ± 9.3 months). The 2-year survival rate in the Drug-group was 82.0%, and the 2-year survival rate, occurrence of right heart failure, and re-vascularization rate in the PEA-group were 97.4%, 2.6%, and 2.8%, and those in the PTPA-group were 98.5%, 2.9%, and 2.9%, respectively.

Conclusion: The patients who underwent interventional therapies had better results than those treated only with drugs. The availability of both of these operative and catheter-based interventional therapies leads us to expect the dawn of a new era of therapeutic strategies for CTEPH.

Conflict of interest statement

Competing Interests: Dr. Toru Satoh spoke on pulmonary hypertension in general in lectures sponsored by Actelion Phamaceuticals, Ltd. This does not alter the authors' adherence to all the PLOS ONE policies on sharing data and materials, as detailed online in the guide for authors.

Figures

Figure 1. Kaplan-Meier curves showing outcome from diagnosis.

Curves show outcome in patients treated with medical therapy alone (Drug-group) (green line) and patients treated with interventional therapy (Interventions-group) (orange line). Patients in the Interventions-group were treated with pulmonary endarterectomy (PEA) and/or percutaneous transluminal pulmonary angioplasty (PTPA). This analysis shows a significantly better outcome in the Interventions-group than in the Drug-group (log-rank test, p

Figure 2. Hemodynamic changes in patients treated with PTPA (PTPA-group) (red boxes) and in patients with PEA (PEA-group) (blue boxes).

Open boxes indicate data before each therapy and solid boxes indicate data at follow-up. Data are shown as boxplot distributions. *: statistically significant (p<0.05) difference between before and after each therapy; †: statistically significant (p<0.05) difference between changes of variables in the two groups; RAP: right atrial pressure; PAP: pulmonary arterial pressure; TPR: total pulmonary resistance.

Figure 3. Changes of distribution of New York Heart Association functional class in PTPA-group and PEA-group.

*: statistically significant (p0.05).

Figure 4. Changes in 6-minute-walk distance (6MWD) and plasma B-type natriuretic peptide (BNP) level in PTPA-group (red boxes) and PEA-group (blue boxes).

Open boxes indicate data before each therapy and solid boxes at follow-up. Data are shown as boxplot distributions. *: statistically significant (p<0.05) difference between before and after each therapy.

Figure 5. Kaplan-Meier curves to evaluate outcomes of two interventional therapies.

Curves show survival rate (A), rate of exacerbation of right heart failure (B), rate of additional re-vascularization (C), and these composite endpoints (D) from the time when each interventional therapy (PTPA or PEA) was performed in patients in PTPA-group (red line) and PEA-group (blue line).