Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary - - PowerPoint PPT Presentation

Ehtisham Mahmud, MD, FACC, FSCAI Professor and Division Chief, Cardiovascular Medicine Director, Sulpizio Cardiovascular Center University of California, San Diego

Balloon Pulmonary Angioplasty for Chronic Thromboembolic Pulmonary Hypertension: Who Should do it?

Disclosures

• No relevant disclosures

Surgical Principles

• Well established1,2

– Median sternotomy – Cardiopulmonary bypass – Circulatory arrest – Bilateral endarterectomy – Identification of the plane – Complete endarterectomy

1-Jamieson et al. Cur Prog Surg 2000, 37:165-252 2-Madani et al. Op Tech in Tho & Card Surg 2006, 11:264-274

UCSD PTE: Pre & Post-op Hemodynamics (N>3000)

200 400 600 800 1000 PVR (dynes/sec/cm-5) 897 245 10 20 30 40 50 Mean PA (mm Hg) 45.9 26 20 40 60 80 Sys PA (mm Hg) 79 45 2 4 6 C.O. (Lit/min) 3.6 5.8 Pre-op Post-op

Surgical Classification of CTEPH

Courtesy Irene Lang, MD

Balloon Pulmonary Angioplasty

• Circulation 2001;103:10-13

CHEST 1988 94:1249-53

• First case report 1988
• First Case Series 2001
• 18 Patients

mPAP 43.0+/-12.1 to 33.7+/-10.2 mmHg (P 0.007) vessels remained patent on follow-up

• (61%) → RPE
• (17%) → Mechanical Ventilation
• (5.6%)→ Mortality

Circ Cardiovasc Interv. 2012;5:748-755.

• 68 patients – 255 sessions
• 4 (2-8) sessions per

patient

• Vascular injury 60%
• 6% required mechanical

ventilation

• 1 death (1.5% mortality)

Okayama Experience with BPA for CTEPH

Pre and Post BPA Left Lower Lobe (A8,9,10): Pressure Gradient Based

A10 A9 A8

Pre and Post BPA Left Lower Lobe (A8,9,10): Pressure Gradient Based

A10 A9 A8 A8: BPA with 2.0 and 3.0 Maverick A9: Pd/Pa based with improvement from 0.40 to 0.52 to 0.82 with 2.0 to 3.0 to 4.0 balloons A10: BPA with 2.0 and 3.0 balloons

Pre and Post BPA Left Lower Lobe (A8,9,10): Pressure Gradient Based

A10 A9 A8

Image Guided Treatment: ?IVUS or OCT

Lang et al. Eur Respir Rev 2017; 26: 160119

Physiology Guided Treatment: Pd/Pa

Inami et al. J Am Coll Cardiol Intv 2014;7:1297–306

Mahmud et al. J Am Coll Cardiol 2018;71:2468-86

UC San Diego Equipment and Approach (2018)

• Single plane angiography (biplane for diagnostic)
• 8-9F venous access sheath: femoral rather than internal jugular
• 6-7F long sheath telescoped through 9F introducing sheath
• 6F guide catheter: multipurpose, Judkins right, Hockeystick, EBU
• Anticoagulation: heparin with ACT 200-250s
• Contrast: 50/50
• 0.014” guide wires; no polymer jacketed wires
• 2-5 mm compliant; NC or Sculpting balloon catheters for recalcitrant
• IVUS and OCT rarely used
• Increasingly using resting pressure gradients (Pd/Pa) to target and optimize

Mahmud et al. Interv Cardiol Clin 2018;7:103-117

Tools for Balloon Pulmonary Angioplasty

Yes

• Pressure wire/catheter
• Sculpting/scoring balloons

No

• Polymer jacketed wires
• Cutting balloon

BPA Complications

– Hemoptysis

• Early Signs

– New Cough – Hypoxia

• Vascular injury

– Wire – Balloon – Contrast

• Imaging

– Vascular leak or stain. – New consolidation in treated areas

– Reperfusion pulmonary edema – Radiation Injury

Management of Acute Hemoptysis During BPA

• 1. Immediate balloon tamponade of the injured vessel
• 2. Oxygenation management including oropharyngeal suctioning, supplemental
• xygen, non-invasive positive pressure ventilation (mechanical ventilation/ECMO)
• 3. Cessation/reversal of anticoagulation
• 4. Repeat prolonged balloon tamponade as necessary
• 5. For persistent pulmonary hemorrhage consider bailout transcatheter coil

embolization, covered stent implantation, and/or gelfoam/adipose injection

Mahmud et al. Interv Cardiol Clin 2018;7:103-117

Approach to Pouch Occlusions: Antegrade Wire Escalation

Be Conservative!!

Restoration of Flow to Pouch Occlusions Works: One Year Later

AP LAO 30

Long-term Outcomes after BPA for CTEPH

Inami et al. Circulation 2016;134:2030–2032

Japan: Clinical and Hemodynamic Data

mPAP (mmHg) p<0.00 1 p<0.001 Before After Follow-up

60 50 40 30 20 43.2±11.0 24.3±6.4 22.5±5.4

p<0.001 p=0.002 Before After Follow-up

4.0 3.5 3.0 2.5 2.0

Cardiac index (L/min/m2)

2.6±0.8 2.9±0.7 2.8±0.6

p<0.001 p<0.001 Before After Follow-up

1500 1250 1000 500 250

PVR (dyne/sec/cm5)

750

853.7±450.7 359.5±222.6 288.1±194.5

WHO functional class

Ⅳ Ⅲ Ⅱ Ⅰ

73 Before After Follow-up 1 1 192 34 6 56 181 130 27 46 p<0.001 p<0.001

WHO-FC Cardiac Index mPAP PVR

p<0.001 p=0.002 p=0.002 p=0.002

Ogawa A et al. Circulation Cardiovasc Outcomes 2017 Nov;10(11). pii: e004029

UC San Diego BPA Registry

Pre-BPA Post-BPA P Value RA (mmHg) 7.9 ± 3.2 PA systolic (mmHg) 74.6 ± 12.9 PA diastolic (mmHg) 24.9 ± 4.9 PA mean (mmHg) 43.4 ± 6.1 PCWP (mmHg) 9.7 ± 3.4 Cardiac output (L/min) 5.7 ± 1.7 Cardiac index (L/m/m2) 2.9 ± 0.7 PVR (WU) 6.4 ± 2.7 Hemodynamics

*For subjects with baseline mPAP >30 and ≥3 BPA procedures (n=28)

UC San Diego BPA Registry

Pre-BPA Post-BPA P Value RA (mmHg) 7.9 ± 3.2 5.5 ± 2.3 <0.01 PA systolic (mmHg) 74.6 ± 12.9 56.1 ± 13.2 <0.01 PA diastolic (mmHg) 24.9 ± 4.9 17.5 ± 4.4 <0.01 PA mean (mmHg) 43.4 ± 6.1 32.5 ± 6.4 <0.01 PCWP (mmHg) 9.7 ± 3.4 9.0 ± 3.4 <0.01 Cardiac output (L/min) 5.7 ± 1.7 5.9 ± 1.2 0.27 Cardiac index (L/m/m2) 2.9 ± 0.7 3.1 ± 0.5 0.08 PVR (WU) 6.4 ± 2.7 4.0 ± 1.7 <0.01 Hemodynamics

*For subjects with baseline mPAP >30 and ≥3 BPA procedures (n=28)

UC San Diego BPA Registry

N = 252 sessions (60 subjects) Hemoptysis 23 (9.1%) Lung vascular injury 9 (3.6%) Reperfusion lung edema Non-invasive PPV Intubation Acute kidney injury Inpatient death Adverse Events

UC San Diego BPA Registry

WHO Functional Class

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Pre-BPA Post-BPA WHO class I WHO class II WHO class III WHO class IV

P <0.01

*For subjects with mPAP >30 and ≥3 BPA procedures

UC San Diego BPA Registry

6-Minute Walk Distance

*For subjects with mPAP >30 and ≥3 2 BPA procedures 361 420 100 200 300 400 500 600 Pre-BPA Post-BPA Meters

P <0.01

Conclusions

• BPA is a feasible therapeutic option for CTEPH patients with:
• -inoperable disease
• -segmental/subsegmental disease
• -post PTE residual disease
• BPA should be performed as a part of a multidisciplinary CTEPH team
• BPA should be physiology based: perfusion scans and invasive hemodynamic measurements
• Future investigation for BPA to focus on:
• -optimal patient selection and acquisition of objective adjudicated data
• -standardized technique and procedural endpoints
• -long-term patency and clinical success
• -registries and randomized controlled trials