Long-term outcomes of combined pulmonary endarterectomy and additional balloon pulmonary angioplasty for chronic thromboembolic pulmonary hypertension

Background The early and long-term outcomes after pulmonary endarterectomy (PEA) for chronic thromboembolic pulmonary hypertension (CTEPH) have been established by several high-volume centers, but the impact of postoperative residual pulmonary hypertension affecting postoperative clinical parameters remains unclear. This study aims to investigate the institutional surgical results of PEA and to evaluate the efficacy of additional balloon pulmonary angioplasty (BPA) for residual pulmonary hypertension. Patients and methods We retrospectively reviewed 222 patients (57.7 +/- 12.9 years old, 141 female) who underwent PEA for CTEPH at the National Cerebral and Cardiovascular Center between 2000 and 2020. Results The preoperative mean pulmonary artery pressure (mPAP) was 45.6 +/- 9.7 mmHg and pulmonary vascular resistance (PVR) was 1062 +/- 451 dyne*sec/cm(-5). Postoperative mPAP (23.4 +/- 11 mmHg, 204 patients, P < 0.001) and PVR (419 +/- 291 dyne*sec/cm(-5), 199 patients, P < 0.001) significantly improved after PEA. Since 2011, 62 patients (28%) underwent BPA after PEA for "catecholamine dependent" residual PH 1 month after PEA in 14, "scheduled" BPA with residual PH 1 year after PEA in 32, and 16 "symptomatic" patients without residual PH. Their mPAP had significantly improved by PEA (48.1 +/- 7.7 to 32.0 +/- 10.2 mmHg, P < 0.001), and further improved (33.8 +/- 11.1 to 26.5 +/- 9.1 mmHg, P < 0.001) after BPA. Conclusions PEA provided immediate and substantial improvements in pulmonary hemodynamics and favorable long-term survival. In addition, postoperative BPA improved postoperative clinical parameters for eligible patients regardless of the presence of residual PH.