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Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension: A Systematic Review and Meta-analysis

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Abstract

Purpose

To perform a systematic review and meta-analysis assessing the safety and efficacy of balloon pulmonary angioplasty (BPA) in the treatment of chronic thromboembolic pulmonary hypertension (CTEPH).

Materials and Methods

Systematic literature searches were performed from inception to June 2022 to identify studies assessing BPA for CTEPH. Outcomes of interest included the following functional and hemodynamic measures: (a) six-minute walk distance (6MWD), (b) New York Heart Association (NYHA) status, (c) World Health Organization (WHO)-Functional Class status, (d) cardiac index (CI), (e) mean pulmonary artery pressure (mPAP), (f) mean right atrial pressure (mRAP), and (g) pulmonary vascular resistance (PVR). Subgroup analysis was also performed for BPA in post-pulmonary endarterectomy (PEA) patients. All reported BPA-related complications were also recorded. Forty unique studies with a total of 1763 patients were identified for meta-analysis.

Results

All functional and hemodynamic parameters improved significantly following BPA; 6MWD increased 70 m (95% CI 58–82; P < 0.001), NYHA class improved by − 0.9 classes (95% CI − 1.0 to − 0.8; P < 0.001), WHO-FC class improved by − 1 classes ((95% CI − 1.2 to − 0.9; P < 0.001), CI increased 0.26 L/min/m2 (95% CI 0.17–0.35; P < 0.001), mPAP decreased − 13.2 mmHg (95% CI − 14.7 to − 11.8; P < 0.001), mRAP decreased − 2.2 mmHg (95% CI − 2.8 to − 1.6; P < 0.001), and PVR decreased − 311 dyne/cm/s−5 (95% CI − 350 to − 271; P < 0.001). Meta-analysis of patients who underwent BPA for persistent pulmonary hypertension post-PEA demonstrated significant improvements in 6MWD, WHO-FC, PVR and mPAP. Most common complications included lung injury (8.16%), hemoptysis (7.07%) and vessel injury (5.05%).

Conclusion

BPA represents a safe and effective treatment option for select individuals with CTEPH with significant improvements in hemodynamic parameters, improved exercise tolerance and a relatively low risk of major complications.

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Abbreviations

CTEPH:

Chronic thromboembolic pulmonary hypertension

PEA:

Pulmonary endarterectomy

BPA:

Balloon pulmonary angioplasty

PRISMA:

Preferred Reporting Items for Systematic Reviews and Meta-Analyses

mPAP:

Mean pulmonary artery pressure

6MWD:

Six-minute walk distance

NYHA:

New York Heart Association

WHO-FC:

World Health Organization-Functional Class

CI:

Cardiac index

mRAP:

Mean right atrial pressure

PVR:

Pulmonary vascular resistance

IVUS:

Intravascular ultrasound

OCT:

Optical Coherence Tomography

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Authors and Affiliations

  1. Department of Medical Imaging, University of Toronto, 200 Elizabeth St, Toronto, ON, M5G 2C4, Canada

    Mary K. Kennedy, Sean A. Kennedy, Kong Teng Tan, Michael C. McInnis & Sebastian Mafeld

  2. Division of Thoracic Surgery, Department of Surgery, University of Toronto, Toronto, ON, Canada

    Marc de Perrot

  3. Statsconsultancy Ltd, Amersham, Buckinghamshire, UK

    Paul Bassett & Laura Donahoe

  4. Division of Respirology, Department of Medicine, University of Toronto, Toronto, ON, Canada

    John Thenganatt & John Granton

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  1. Mary K. Kennedy
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MCM received personal fees from Bayer and Boehringer Ingelheim outside the submitted work. JG reports unrestricted financial support for education and research to the hospital foundation from Bayer and Jannsen and is a member of the Canadian Thoracic Society executive committee. MP received personal fees from Actelion, AstraZeneca, Bayer and Roche outside the submitted work. Remaining authors report no relevant conflicts of interest.

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Kennedy, M.K., Kennedy, S.A., Tan, K.T. et al. Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension: A Systematic Review and Meta-analysis. Cardiovasc Intervent Radiol 46, 5–18 (2023). https://doi.org/10.1007/s00270-022-03323-8

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