Chronic Thromboembolic Pulmonary Hypertension

Chronic Thromboembolic Pulmonary Hypertension

Pulmonary hypertension due to unresolved pulmonary emboli that narrow pulmonary arteries, also known as chronic thromboembolic pulmonary hypertension (CTEPH), is a deadly disease that can be effectively treated with a complex surgical procedure called pulmonary thromboendarterectomy (PTE). Since 2011, Cleveland Clinic has a multidisciplinary team dedicated to the evaluation and treatment of CTEPH patients. The team includes clinicians specializing in pulmonary medicine, cardiothoracic surgery, interventional radiology, chest radiology, nuclear medicine, cardiovascular medicine, anesthesiology, and critical care medicine.

During the past 27 years, 351 PTE surgeries have been performed at Cleveland Clinic. Between 1995 and 2010, operative mortality (ie, in-hospital deaths) was 11.6%. Between 2011 and 2021, surgical volume more than doubled and the operative mortality decreased to 2.6%, a rate comparable to or better than current published literature. ¹ ²

Treatment options are expanding. Cleveland Clinic now offers PTE surgery to carefully selected patients with normal resting pulmonary hemodynamics who are symptomatic from chronic thromboembolic disease (CTED) as evidenced by invasive cardiopulmonary exercise testing.¹ ²

Pulmonary Thromboendarterectomy Experience (N = 351)

2011 – 2021

Treatment options are expanding. Cleveland Clinic now offers PTE surgery to carefully selected patients with normal resting pulmonary hemodynamics who are symptomatic from chronic thromboembolic disease (CTED) as evidenced by invasive cardiopulmonary exercise testing.¹ ²

PTE = pulmonary thromboendarterectomy

Balloon Pulmonary Angioplasty (BPA) Experience 2016 – 2021 (80 Patients and 325 Sessions)

2016 – 2021

For selected patients with inoperable CTEPH or residual pulmonary hypertension after PTE, balloon pulmonary angioplasty (BPA) has emerged as a potential treatment option. Between 2016 and 2021 the team has treated 80 patients for a total of 216 BPA sessions. BPA was perfomed for technically inoperable disease in 82% of cases, residual pulmonary hypertension after PTE in 14%, and operable disease but poor surgical candidacy in 4%. Mean number of BPA sessions per patient is 4. The procedure is well tolerated, with a low complication rate (6.25% of sessions, 17.8% of patients, mild severity) and no mortality. Patients experience functional and hemodynamic improvements.

BPA = balloon pulmonary angioplasty, PTE = pulmonary thromboendarterectomy

Improvements in Symptoms, Exercise Capacity, and Hemodynamics With BPA

2011 – 2021

ParametersPre-BPAPost-BPAP value
Mean pulmonary artery pressure in mm Hg (+/- SD)43 +/- 1435 +/- 12P < 0.001
Pulmonary vascular resistance in Wood units6.3 +/- 3.74.6 +/- 2.5P = 0.015
Cardiac index in L/min/m²2.58 +/- 1.182.81 +/- 0.70P = 0.579
Mean 6 MWD in feet (+/- SD)982 +/- 5101151 +/- 394P = 0.058
Mean NT-proBNP in pg/mL (+/- SD)1969 +/- 2989788 +/- 1519P = 0.0047
Mean NYHA class (+/- SD) 2.8 +/- 0.62.2 +/- 0.9P < 0.001

BPA = balloon pulmonary angioplasty, MWD = minute walk distance, NT-proBNP = N-terminal proB-type Natriuretic Peptide, NYHA = New York Heart Association

References

  1. Mayer E, Jenkins D, Lindner J, D’Armini A, Kloek J, Meyns B, Ilkjaer LB, Klepetko W, Delcroix M, Lang I, Pepke-Zaba J, Simonneau G, Dartevelle P. Surgical management and outcome of patients with chronic thromboembolic pulmonary hypertension: results from an international prospective registry. J Thorac Cardiovasc Surg. 2011 Mar;141(3):702-710.

  2. Madani MM, Auger WR, Pretorius V, Sakakibara N, Kerr KM, Kim NH, Fedullo PF, Jamieson SW. Pulmonary endarterectomy: recent changes in a single institution’s experience of more than 2,700 patients. Ann Thorac Surg. 2012 Jul;94(1):97-103; discussion 103.