Chronic thromboembolic pulmonary hypertension: surgery entails encouraging long-term results

Pulmonary endarterectomy (PEA) is the treatment of choice in over 80% of patients with chronic thromboembolic pulmonary hypertension (CTEPH) and yielded reassuring long-term outcomes. Interestingly, no long-term differences were found when compared with balloon pulmonary angioplasty (BPA) outcomes.

“Historically, the only treatment available for CTEPH was surgery, which is PEA, and it only targets proximal disease distributions. However, there are more and more patients also coming up with more distal disease, so, more recently, BPA and medical therapy were established to target the more distal disease,” Dr Paula Appenzeller (University of Zürich, Switzerland) explained the common practice [1]. Currently, the treatment decision in UK patients with CTEPH is made by a multidisciplinary team that considers factors like anatomical clot distribution, operability, and patient’s choice.

The presented analysis for long-term outcomes of the 3 available therapies included over 1,300 patients treated between 2015 and 2022, of whom 82% received PEA. The other 2 possible modalities of therapy consisted of either BPA or non-interventional (NI) medical treatment.
At baseline, the 3 groups varied significantly in median age: 60 years in PEA, 67 years in BPA, and 74 years in NI (P<0.001). Other significant differences between the groups included the median values for the 6-minute walking test and NT-proBNP. The groups also differed in baseline mean pulmonary artery pressure (mPAP): PEA 46 mmHg, BPA 41 mmHg, and NI 44 mmHg. At follow-up, the median difference in mPAP in the PEA, BPA, and NI arms were -17 mmHg, -8 mmHg, and -1 mmHg, respectively. Median difference in pulmonary vascular resistance in dynes/s/cm^-5 reached -353 (PEA), -175 (BPA), and -147 (NI). A Kaplan-Meier-analysis revealed a 3-year survival of 91% in the PEA arm, 96% in the BPA arm, and 64% in the NI arm. When early deaths after surgery were excluded, the comparison between 3-year survival after PEA and BPA did not yield a statistical difference (P=0.98).
Dr Appenzeller stated that the study showed excellent long-term survival in CTEPH patients treated by an intervention, with no significant difference between PEA and BPA at 3 years. “To offer multimodality treatment and to optimise outcome for an individual patient, an experienced multidisciplinary team is needed to provide treatment selection, as the treatments may be used alongside each other but they are not interchangeable, as they target different disease distributions,” Dr Appenzeller concluded.

1. Appenzeller P. Long term outcome in chronic thromboembolic pulmonary hypertension in the multimodality treatment era: a UK national cohort analysis. Abstract 741, ERS International Congress 2023, 9–13 September, Milan, Italy.

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Posted on 29 October, 202329 October, 2023