Novel outpatient balloon pulmonary angioplasty protocol safe and effective in CTE pulmonary hypertension

It is already known that Balloon pulmonary angioplasty is currently performed at expert centres worldwide. The procedure treats patients with chronic thromboembolic pulmonary hypertension (CTEPH) and symptomatic chronic thromboembolic pulmonary disease (CTEPD), improving both parameters: symptoms and hemodynamics. The procedure has associated risks and complications like vascular injury and pulmonary oedema. The current practice standard is inpatient postprocedural monitoring for 24 to 72 hours.

A team of researchers evaluated the safety and efficacy of BPA in a cohort of CTEPD and CTEPH patients and outlined a protocol for implementation in the outpatient setting.

The Michigan Medicine Outpatient Balloon Pulmonary Angioplasty Protocol can be summarised as follows:

Pre-procedure:

• Imaging evaluation.
• Individual patient clinical and anatomic risk stratification.
• Multidisciplinary CTEPH team evaluation.
• Hemodynamic optimization with pulmonary vasodilators.

Intra-procedure:

• Utilize light sedation.
• Limit interventions to 3-4 unilateral pulmonary segments per procedure.
• Subselective segmental angiography for lesion characterization.
• Dilatation until brisk venous return is established.
• Adjunctive pressure-wire dilation guidance
• Diluted contrast is limited to 3× the patient's GFR per procedure.
• Radiation exposure is limited to 2 Gy per procedure.
• Advanced airway, interventional and invasive contingencies on standby.

Post-procedure:

• Immediate post-procedural chest x-ray.
• 2 hours of bed rest
• After 2 hours, initiation of anticoagulation with IV heparin.
• 8-12 hours of specialized nursing monitoring in the observational unit.
• Follow up via teleconsultation after finishing 2 BPA sessions.

The Results could be summarised as:

• Eighteen patients underwent 78 BPA sessions in total.
• The improvement in World Health Organization, functional class, and mean improvement in 6-minute walking distance of +67 m was recorded.
• There was an improvement in hemodynamic parameters with a mean decrease in mean pulmonary artery pressure and pulmonary vascular resistance of 7.3 ± 5.8 mm Hg and 1.7 ± 1.5 Wood units, respectively.
• There were low Complication rates.
• 3/78 patients constituting 3.9 %, developed scant hemoptysis.
• One patient had a vascular injury requiring inpatient hospitalization.

They said BPA is safe and effective while performed in the outpatient setting with a standardized protocol with readily available contingencies. Our protocol was borne out of necessity due to healthcare constraints of the COVID-19 pandemic."

The study's limitations include limited patients and standardization of medical therapy, which was not uniform across all patients.

Our results demonstrated improvements in parameters and had low complication rates attributed to an experienced, multidisciplinary BPA team with refined technical expertise comparable with those reported based on multicenter registries, they wrote.

"We do not recommend new programs initiating BPA implement our outpatient postprocedural monitoring. Instead, they wrote that it should be implemented once enough experience is obtained".

Further reading:

Safe and Effective Balloon Pulmonary Angioplasty in the Outpatient Setting: The Michigan Medicine Experience. https://doi.org/10.1016/j.jscai.2023.100589