CLINICAL STUDY

Balloon Pulmonary Angioplasty for the

Treatment of Nonoperable Chronic
Thromboembolic Pulmonary Hypertension:
Single-Center Experience with Low Initial
Complication Rate
Laurent Godinas, MD, PhD, Lawrence Bonne, MD,
Werner Budts, MD, PhD, Catharina Belge, MD, PhD, Mathias Leys, MD,
Marion Delcroix, MD, PhD, and Geert Maleux, MD, PhD
ABSTRACT

Purpose: To evaluate the safety and efficacy of balloon pulmonary angioplasty (BPA) for nonoperable chronic thromboembolic
pulmonary hypertension (CTEPH) patients during the initial experience of a single center.
Methods: A total of 18 CTEPH patients (5 with residual pulmonary hypertension after pulmonary endarterectomy) were treated with
BPA during the period 2014–2018 and were retrospectively reviewed. Mean age was 61 ± 19 years; 55% were female; mean pulmonary
artery pressure was 44 ± 12 mmHg; cardiac output was 4.3 ± 1.0 l/min; and pulmonary vascular resistance was 8.4 ± 3.6 WU. Patients
were evaluated by New York Heart Association functional class, 6-minute walk distance, N-terminal pro b-type natriuretic peptide,
echocardiography, right heart catheterization, and before and after completions of BPA.
Results: A total of 91 procedures were performed, with a median number of 4 BPA sessions per patient (range, 2–8). There were no
deaths or major complications requiring extracorporeal support or (non)invasive ventilation. The most common complication was
self-limiting hemoptysis (3%). According to Society of Interventional Radiology classification, 4 mild, 4 moderate, and 1 severe adverse
events were noted. Invasive hemodynamics significantly improved, with a cardiac index increase of 15% (P ¼ .0333), decrease of mean
pulmonary artery pressure of 30% (P ¼ .0013), and decrease of pulmonary vascular resistance of 45% (P ¼ .0048). Stroke volume index
(P ¼ .0171) and pulmonary arterial compliance (P ¼ .0004) were also significantly enhanced.
Conclusions: BPA significantly improves cardiopulmonary hemodynamics with an acceptable safety profile. Further studies assessing
the long-term efficacy of BPA are required.

ABBREVIATIONS

BPA ¼ balloon pulmonary angioplasty, CI ¼ cardiac index, CO ¼ cardiac output, CTEPH ¼ chronic thromboembolic
pulmonary hypertension, dPAP ¼ diastolic pulmonary artery pressure, HR ¼ heart rate, mPAP ¼ mean pulmonary artery pressure,
NT-proBNP ¼ N-terminal pro b-type natriuretic peptide, NYHA ¼ New York Heart Association, PAC ¼ pulmonary arterial compli-
ance, PAWP ¼ pulmonary artery wedge pressure, PEA ¼ pulmonary endarterectomy, PH ¼ pulmonary hypertension, PP ¼ pulse
pressure, PVR ¼ pulmonary vascular resistance, RV ¼ right ventricle, sPAP ¼ systolic pulmonary artery pressure, SV ¼ stroke
volume, SVI ¼ stroke volume index

Chronic thromboembolic pulmonary hypertension (CTEPH)

From the Departments of Pneumology (L.G., C.B., M.L., M.D.) and Radiology (L.B.,
G.M.), and Division of Cardiology (W.B.), University Hospitals Leuven, Herestraat
49, 3000 Leuven, Belgium; Department of Cardiovascular Sciences (W.B.), Catholic
University Leuven, Leuven, Belgium; and Department CHROMETA, Division of
Pneumology (C.B., M.D.), KU Leuven, Leuven, Belgium. Received November 23,
2018; final revision received February 25, 2019; accepted March 17,
2019. Address correspondence to L.G.; E-mail: Laurent.Godinas@uzleuven.be
None of the authors have identified a conflict of interest.
© SIR, 2019
J Vasc Interv Radiol 2019; 30:1265–1272
https://doi.org/10.1016/j.jvir.2019.03.023
is an increasingly recognized cause of pulmonary hyper-
tension (PH) and is associated with high mortality and
morbidity (1). CTEPH is mostly caused by the persistence
of thrombi after an episode of acute pulmonary embolism
(2). Pulmonary vascular obstruction impairs right ventricle
(RV) function, leading to dyspnea, exercise limitation, and
right heart failure. Pulmonary endarterectomy (PEA) is the
recommended treatment for patients deemed operable and
for whom clots are proximal and surgically accessible (3,6).
However, not all patients are eligible for PEA, and there is a
need for efficient treatments for nonoperable CTEPH
1266 ▪ BPA for the Treatment of Nonoperable CTEPH Godinas et al ▪ JVIR

patients (4). Balloon pulmonary angioplasty (BPA) is a Table 1. Demographic, Clinical, and Hemodynamic
recently developed minimally invasive technique that con- Characteristics of the Patients
sists of breaking down intraluminal obstructive webs with
balloon dilatations (7). In patients who are not suitable for Baseline CTEPH
surgery, BPA has been shown to improve hemodynamics, patients n ¼ 18
exercise tolerance, echocardiographic parameters of right Age, y 61 ± 19
heart function, and symptoms in retrospective, single-center Sex, M/F 8/10
studies (7). Due to these promising results, BPA has been BMI, kg/m2 26.7 ± 5.7
progressively implemented in PH centers, although the Previous PEA, % 22%
place of BPA remains not clearly defined in the therapeutic NYHA FC, I/II/III/IV 1/14/3/0
algorithms of CTEPH guidelines (3,8). Furthermore, severe 6MWD, m 412 ± 167
adverse events have been reported, including deaths related NTproBNP, ng/ml 1409 ± 987
to the procedure, wire perforations, high-pressure reperfu- mPAP, mmHg 44 ± 12
sion injuries, and pulmonary artery ruptures (9,10), espe- PAWP, mmHg 9±3
cially during the learning phase of early experience. In this RAP, mmHg 8±4
study, we sought to report our initial single-center experi- CO, l/min 4.3 ± 1.0
ence with safety and efficacy assessment of BPA in patients CI, l/min/m2 2.3 ± 0.4
with inoperable CTEPH. PVR, WU 8.4 ± 3.6
TPR, WU 10.6 ± 4.2
SvO2, % 64 ± 9
MATERIALS AND METHODS Treatments, %
Study Design No specific treatment 28
Patients who underwent BPA between July 2014 and July Monotherapy 33
2018 were included, and their charts were retrospectively Double therapy 33
reviewed. Informed consent was obtained from the patients Triple therapy 6
before each BPA procedure, and ethical approval was ob- Specific PAH therapies, %
tained from the institutional review board. sGC 33
ERA 55
PDE5i 28
Patient Selection IV prostanoid 11
CTEPH diagnosis was established according to guidelines
and consisted of precapillary PH associated with mis- Note–Results are expressed as mean ± standard deviation or
median (range).
matched perfusion defects evaluated by ventilation/perfu-
6MWD ¼ 6-minute walk distance; BMI ¼ body mass index; CI ¼
sion scan and pulmonary angiogram displaying pulmonary cardiac index; CO ¼ cardiac output; ERA ¼ endothelin receptor
vascular obstruction (3). The non-operability of the patients antagonist; IV ¼ intravenous; mPAP ¼ mean pulmonary artery
was assessed after evaluation by an experienced team that pressure; NTproBNP ¼ N-terminal pro b-type natriuretic pep-
included PH physicians, PEA specialized surgeons, and tide; PEA ¼ pulmonary endarterectomy; NYHA FC ¼ New York
Heart Association functional class; PAWP ¼ pulmonary artery
radiologists. All patients were deemed inoperable due to
wedge pressure; PDE5i ¼ phosphodiesterase type 5 inhibitor;
distal disease not accessible to PEA. PVR ¼ pulmonary vascular resistance; RAP ¼ right atrial
pressure; sGC ¼ soluble guanylate cyclase stimulator; SvO2 ¼
mixed venous oxygen saturation; TPR ¼ total pulmonary
Baseline Assessment resistance.
Eighteen nonoperable CTEPH patients were treated by BPA.
The mean age was 61 ± 19 years. Patients had moderate
symptoms (1, 14, and 3 patients were in New York Heart cyclase stimulator, 6; phosphodiesterase type 5 inhibitor, 5;
Association (NYHA) functional class I, II, and III, respec- intravenous prostanoid, 2; monotherapy, 5; double therapy,
tively). Mean 6-minute walk distance was 412 ± 167 m. The 7; and triple therapy, 1). Demographic characteristics and
median N-terminal pro b-type natriuretic peptide (NT- hemodynamics at baseline are shown in Table 1.
proBNP) blood level was 1409 ± 987 ng/ml. Baseline he-
modynamics showed severe precapillary PH, with a mean BPA Procedures
pulmonary artery pressure (mPAP) of 44 ± 12 mmHg, a The procedures were performed by a team of 4 members,
cardiac output (CO) of 4.3 ± 1.0 l/min, and pulmonary consisting of 2 interventional radiologists, 1 interventional
vascular resistance (PVR) of 8.4 ± 3.6 WU. Five patients cardiologist, and 1 respiratory physician specialized in PH,
had residual PH after PEA. Thirteen patients were treated by with BPA experience of 4, 2, 3, and 2 years, respectively, after
1 or more pulmonary arterial hypertension-specific therapies visiting high-volume centers in Japan, Norway, and France. A
(endothelin receptor antagonist, 10; soluble guanylate 7-Fr sheath was introduced by a venous femoral access and
Volume 30 ▪ Number 8 ▪ August ▪ 2019 1267

Figure 1. Selective angiography and balloon pulmonary angioplasty in a sub-segmental pulmonary artery. (a) Two branches of the left
A8 segment are underperfused and nearly occluded (black arrow) due to the presence of intraluminal material. (b–d) Inflation of balloons
at different localizations using balloons sized 2.0 x 20.0 mm to 4.0 x 20.0 mm after wire catheterization of the vessels. (e) Results after
balloon inflation. There are now distinct vessels visible with an increased local perfusion surrounding the vessel. (f) Note the increased
visibility of the pulmonary vessels.

guided into the pulmonary artery under fluoroscopy. At the

beginning of each procedure, pulmonary pressure measure-
ments and unilateral pulmonary angiography were performed.
Afterwards, a 6-Fr guiding catheter (Envoy; Codman, Rayn-
ham, Massachusetts) was selectively inserted in the segmental
arteries where a more selective angiography was made,
allowing the selection of the targeted vessels and lesions. A
0.014-inch guidewire catheter (Hi-Torque Balance Middle-
weight; Abbott, Chicago, Illinois) was pushed across the pul-
monary vasculature and the observable lesions. An inflatable
balloon (Coyote 0.014 Balloon Dilatation Catheter; Boston
Scientific, Marlborough, Massachusetts) was conducted
through the stenotic lesions before inflation to nominal size.
The first balloon used in a vessel was systematically under- Figure 2. Representation of the total number of BPA sessions
sized to avoid vascular rupture. The final size of the balloon per patient.
and the number of inflations requested were judged according
to the size of the vessels, distribution of lesions, degree of distal
revascularization, and the appearance of pulmonary venous of the pulmonary angiogram, the hemodynamic changes,
return. An example of results achieved is shown in Figure 1. and the tolerance of each patient.
The procedure was conducted without withdrawal of
anticoagulation (international normalized ratio, 2–3) and Post-procedure Evaluation and Follow-up
under systemic heparin, according to the discretion of the Complications were evaluated and reported using the new
treating operator. The total number of BPA procedures was Society of Interventional Radiology Adverse Event Classi-
tailored according to the clinical response, the improvement fication System (11). The clinical protocol included a
1268 ▪ BPA for the Treatment of Nonoperable CTEPH Godinas et al ▪ JVIR

Table 2. Complications Recorded during and after 30 Days after BPA

BPA procedure n ¼ 91 SIR classification

Mild Moderate Severe Life-threatening
Hemoptysis
Distal wire perforation 3 2 1 0 0
Pulmonary artery rupture 0 0 0 0 0
BPA-related lung injury 2 0 2 0 0
Arrhythmia 2 1 1 0 0
Contrast allergy 1 1 0 0 0
Stress cardiomyopathy 1 0 0 1 0
Death 0

BPA ¼ balloon pulmonary angioplasty; SIR ¼ Society of Interventional Radiology.

Table 3. Functional Capacity and Echocardiography Results

before and after BPA
Before BPA n ¼ 18 After BPA n ¼ 18
NYHA FC 2 (1–4) 2 (1–3)
6MWD, m 412 ± 167 402 ± 196
NTproBNP, ng/ml 425 (120–807) 284 (44–2761)
RV/LV 1.1 ± 0.6 1.0 ± 0.6
sPAP(TTE), mmHg 63 ± 23 54 ± 19
TAPSE, mm 19 ± 4 20 ± 4
Note–Changes were not significant. Results are expressed as
mean ± standard deviation or median (range).
6MWD ¼ 6-minute walk distance; NYHA FC ¼ New York Heart
Association functional class; RV/LV ¼ ratio of right ventricle
and left ventricle area, assessed by echocardiography;
sPAP(TTE) ¼ systolic pulmonary artery pressure, assessed by
transthoracic echocardiography; TAPSE ¼ tricuspid annular
plane systolic excursion.
systematic assessment 3 months after the last BPA proced-
ure, comprising NYHA functional class evaluation, 6-
minute walk distance test, echocardiography, NT-proBNP,
and right heart catheterization. During right heart catheter-
ization, measurements of systolic pulmonary artery pressure
(sPAP), diastolic pulmonary artery pressure (dPAP), and
mPAP, right atrial pressure, and pulmonary artery wedge
pressure (PAWP) were performed. CO was measured using
the thermodilution technique. Total pulmonary resistance
was calculated as mPAP/CO, and PVR was calculated as
(mPAP-PAWP)/CO. Stroke volume index (SVI) was calcu-
lated using cardiac index (CI) divided by heart rate (HR).
Pulmonary arterial compliance (PAC) was assessed using
the ratio of SV (CO/HR) and pulse pressure (PP) (ie, sPAP-
dPAP).
Statistical Analysis
Comparisons of the results were performed using a paired t-
test for normally distributed data or the Wilcoxon test for
paired data. Categorical variables were analyzed using the
chi-square test. A P value less than .05 was considered
significant. Statistical analyses were performed using Prism
v7 (GraphPad Software Inc, San Diego, California).
RESULTS
BPA Procedure
A total of 91 procedures were performed in the cohort of 18
patients. A median number of 4 BPA sessions (range, 2–8)
were performed (Fig 2). Median time between the first and
the last BPA procedure was 243 days (range, 36–1008
days). Only 2 patients received fewer than 4 BPA
sessions, due to patient consent withdrawal to undergo
any additional BPA. The median follow-up time between
the last BPA procedure and the last evaluation was 471 days
(range, 133–937 days).
Safety
The procedure was well tolerated in all the patients. The
adverse events during the procedure and at 30 days after
each BPA session are displayed in Table 2. No deaths were
related to the BPA procedures or occurred during the first 30
days after a BPA session. According to the new Society of
Interventional Radiology classification, complications were
rated as follows: 4 mild, 4 moderate, and 1 severe. Three
(3%) episodes of hemoptysis due to wire distal perforation
without pulmonary artery rupture were observed. One
episode resolved after immediate coil embolization; the
others responded to prolonged obstructing balloon
inflation. An episode of supraventricular tachycardia was
noted in 1 patient, which spontaneously resolved. One
patient experienced atrial fibrillation 1 week after a BPA
procedure, requiring amiodarone, electrical cardioversion,
and catheter ablation. Two minor groin hematomas
without significant drop in hemoglobin were noted. One
patient complained of stridor due to contrast medium
allergy. Another patient developed acute stress
cardiomyopathy with thoracic pain, rise in troponin, and
diffuse left ventricle akinesia with normal coronary
angiography. The patient spontaneously recovered with
normalization of left ventricle function and underwent
further BPA sessions without complication. One patient
suffered from mild BPA-related lung injury during 2 sepa-
rate BPA procedures. The diagnosis was made based on
lung infiltrates on the chest-X-ray and requirement of nasal
Volume 30 ▪ Number 8 ▪ August ▪ 2019 1269

Figure 3. Evolution of the functional class, functional capacity, and echocardiographic parameters, before and after BPA. (a) Symptoms
assessed by the NYHA functional classification (P ¼ .34). (b) 6-minute walk distance (P ¼ .48). (c) N-terminal pro b-type natriuretic peptide
(P ¼ .27). (d) Systolic pulmonary artery pressure assessed by echocardiography in the presence of a tricuspid regurgitation (P ¼ .24). (e)
Ratio of the right ventricle to the left ventricle (P ¼ .20). (f) Tricuspid annular plane systolic excursion (P ¼ .87).

oxygen. There were no severe BPA-related lung injuries that
required noninvasive ventilation, mechanical ventilation, or
extracorporeal membrane oxygenation.
Symptoms, Exercise Capacity,
Biomarkers, and Echocardiography
After BPA procedures, no statistically significant improve-
ment of NYHA functional class, NT-proBNP levels, or 6-
minute walk distance was noted (Table 3, Fig 3).
Furthermore, echocardiographic parameters, such as sPAP,
RV size, and RV systolic function, did not improve after BPA.
pulmonary hemodynamics but not significantly symptoms
assessed by NYHA functional class, 6-minute walk dis-
tance, biomarkers, and echocardiographic parameters.
Several studies retrospectively assessed the efficacy and
safety of BPA. However, most studies demonstrated a sig-
nificant rate of adverse events as well as mortality related to
BPA (7). The first main finding of the current study was the
acceptable safety profile of BPA. No deaths or severe
complications were reported. The rate of severe complica-
tions was notably lower compared to other reported series,
especially when the effect of a learning curve of a new BPA
service is considered (12,13). Indeed, most studies reported

Invasive Hemodynamics
Fourteen patients had an invasive hemodynamic evaluation Table 4. Hemodynamics before and after BPA
after completion of the complete set of BPA procedures Before BPA n ¼ 18 After BPA n ¼ 14
(Table 4). Four patients declined right heart catheterization mPAP, mmHg 44 ± 12 31 ± 12†
after BPA. Time interval between the last BPA and the RAP, mmHg 8±4 7±5
invasive hemodynamic evaluation was 72 days (range, CO, l/min 4.3 ± 1.0 5.0 ± 1.1*
26–282 days). Hemodynamics were markedly improved CI, l/min2 2.3 ± 0.4 2.7 ± 0.6†
after the last BPA session compared to baseline: mPAP PVR, WU 8.4 ± 3.6 4.6 ± 3.3†
decreased by 30% (P ¼ .0013), PVR decreased by 45% SvO2, % 64 ± 9 66 ± 5
(P ¼ .0048), and CI increased by 15% (P ¼ .0333). HR, /min 74 ± 14 70 ± 12
Additionally, SVI and PAC were also significantly SVI, ml/m2 32 ± 5 40 ± 9*
increased (P ¼ .0171 and P ¼ .0004, respectively). The PACSV/PP, ml/mmHg 1.30 ± 0.51 2.24 ± 0.96‡
individualized hemodynamic results are displayed in
Figure 4. Figure 5 shows the mPAP achieved after BPA Note–Results are expressed as mean ± standard deviation or
completion, with 43% patients achieving an mPAP below median (range). Changes without asterisk are not significant.
CO ¼ cardiac output; HR ¼ heart rate; mPAP ¼ mean pulmo-
25 mmHg. nary artery pressure; PAC ¼ pulmonary arterial compliance;
PAWP ¼ pulmonary artery wedge pressure; PP ¼ pulse pres-
sure (sPAP - dPAP); PVR ¼ pulmonary vascular resistance;
DISCUSSION RAP ¼ right atrial pressure; SVI ¼ stroke volume index; SvO2 ¼
mixed venous oxygen saturation.
In this study, the outcomes of 91 BPA procedures in 18 *P < .05.
nonoperable CTEPH patients were presented. The results †
P < .01.
‡
show that BPA was safe and well tolerated, improving P < .001.
1270 ▪ BPA for the Treatment of Nonoperable CTEPH Godinas et al ▪ JVIR

Figure 4. Evolution of hemodynamics before and after BPA for each of the 14 patients who had invasive hemodynamic evaluation. (a)
Mean pulmonary artery pressure (P ¼ .0015). Dotted line represents the cutoff value of 25 mmHg. (b) Cardiac index (P ¼ .0042). (c)
Pulmonary vascular resistance (P ¼ .0052). Dotted line represents the cutoff value of 3 WU. (d) Right atrial pressure (P ¼ .72). (e) Mixed
venous oxygen saturation (P ¼ .75). (f) Heart rate (P ¼ .62). (g) Stroke volume index (P ¼ .0171). (h) Pulmonary arterial compliance
assessed by the ratio of stroke volume and pulse pressure (P ¼ .0004).

higher rates of adverse effects and deaths attributable to
BPA (7). In the Japanese registry, which included 308 pa-
tients from 7 centers, mortality was 2.6%, and complications
occurred in 36% of patients (12). The current study high-
lights the fact that a BPA program could be safely initiated
with acceptable safety profile in a specialized PH center,
provided that a cautious approach is taken combined with
appropriate training in high-volume centers.
The second important finding in this cohort was the he-
modynamic improvement after BPA. The observed decrease
in mPAP (30%) and PVR (45%) are in line with other re-
ports (14–18). Although hemodynamic goals of BPA remain
a matter of debate, normalization or near normalization of
hemodynamics (ie, mPAP 25 mmHg) has been proposed
as the optimal target (19). Indeed, in this study, a high
proportion of the patients achieved mPAP 25 mmHg.
Other experienced BPA centers have also reported that a
large proportion of patients can achieve hemodynamic
normalization (20–22), and this goal seems realistic with
increasing experience and refinement of BPA technique.
However, these results also demonstrate that clinical and
hemodynamic response can be heterogeneous (23). Some
patients seem to respond to BPA with a dramatic hemody-
namic improvement, whereas others experience only minor
change or no change. The possible predominance of
microvascular disease in non-responder patients has been
proposed to explain the failure of BPA in some patients (24).
Interestingly, several patients with a longstanding diagnosis
of CTEPH were included in this study, and these patients
could be more prone to present with distal micro-
vasculopathy, which cannot be treated by BPA (25,26).
However, the small number of patients precludes any
definitive conclusion, and factors influencing the outcomes
of BPA require further study.
In addition to improvement of conventional hemodynamic
parameters (mPAP, CO, and PVR), it was found that BPA
also improved SVI and PAC. SVI is a robust parameter linked
to prognosis in patients with pulmonary arterial hypertension
(27), and it has been recently suggested that SVI was the
most important hemodynamic variable in the follow-up of
PAH under medical therapy (28). In the current cohort,
SVI rise was responsible for the improvement of CO without
any change in HR. The decrease of RV afterload and
improved ventriculo-arterial coupling after BPA explains the
rise of CO (29). Indeed, it is postulated that the dilatation of
webs and bands obstructing the pulmonary vascular lumen
allows the blood flow to circulate more easily with lower
turbulences (30), diminishing the RV afterload and unloading
the cardiac pump. Moreover, the compliance of the pulmo-
nary vessels, assessed by the ratio of SV and PP, was also
improved. Thus, the clinical improvement attributed to BPA
in several cohorts could be due not only to decrease in
vascular resistance (ie, a smoother blood flow in the pulmo-
nary artery) but also to improved vascular compliance (ie, an
intrinsic change in the mechanical properties of the pulmo-
nary vessels).
Figure 5. Representation of the mPAP before (red) and after
(green) final BPA procedure for each patient.
Volume 30 ▪ Number 8 ▪ August ▪ 2019
Interestingly, these hemodynamic changes were not
detected by echocardiography in this study, although other
series reported improvement of RV function parameters
after BPA (15). This suggests that assessment with right
heart catheterization is mandatory to assess the hemody-
namic effects of BPA.
Improvements in NYHA functional class, 6-minute walk
distance, or echocardiography parameters were not demon-
strated. However, a positive trend was noted. Some previous
series demonstrated an improvement in functional capacity
and symptoms (15,17,20,22,31). The seemingly contradic-
tory result reported in the current study is probably due to
insufficient number of patients treated, insufficient number
of sessions per patient, or the relatively higher functional
capacity of the patients at baseline. Indeed, most patients
were in NYHA functional class II, and most experienced
symptom improvements but did not become asymptomatic
(ie, NYHA functional class I) (32). Moreover, the functional
capacity assessed by 6-minute walk distance was not
significantly improved. This could be due to a large number
of patients walking more than 450 meters at baseline with a
test known to present a “ceiling effect” (33). Another
explanation is that the patients would benefit from a reha-
bilitation program to improve their functional capacity and
symptoms after a prolonged period of reduced exercise ca-
pacity, requiring long-term follow-up beyond 6 months
(5,27,34).
This study had several limitations. First, it included a small
number of patients, partially explaining the negative results
for parameters other than invasive hemodynamics and pre-
cluding conclusions about clinical improvement assessed
with NYHA functional class. Second, it was an observational,
retrospective, single-center study. Thus, it could be poten-
tially biased by the effect of a learning curve, and it could be
hypothesized that the results of BPA will improve with
accumulating experience. Moreover, a biased selection could
influence these results due to selection of CTEPH patients
who have had the disease for a long time. Furthermore, 4
patients did not complete hemodynamic evaluation at the end
of BPA, and long-term follow-up is lacking.
In conclusion, this report was of a single-center experi-
ence with the initiation of a BPA program for patients with
inoperable CTEPH. A major improvement in invasive he-
modynamic parameters was demonstrated, similar to the
experience reported in the literature. BPA is relatively safe
even during the learning phase of a new program, as long as
adequate training is provided. The improvement after BPA
could be mediated by decrease in PVR but also by increased
PAC. The long-term beneficial effects of BPA deserve
further study.
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