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Original research
Right ventricular remodelling and long-term survival after pulmonary endarterectomy versus balloon pulmonary angioplasty in chronic thromboembolic pulmonary hypertension
  1. Håvard Ravnestad1,2,
  2. Klaus Murbræch1,
  3. Eyvind Gjønnæss3,
  4. Rune Andersen3,
  5. Natasha Moe3,
  6. Sigurd Birkeland4,
  7. Morten Svalebjørg5,
  8. Per Snorre Lingaas4,
  9. Einar Gude1,
  10. Lars Gullestad1,2,
  11. John-Peder Escobar Kvitting2,4,
  12. Kaspar Broch6,
  13. Arne K Andreassen1
  1. 1Department of Cardiology, Oslo University Hospital, Oslo, Norway
  2. 2Institute of Clinical Medicine, University of Oslo, Oslo, Norway
  3. 3Department of Radiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
  4. 4Department of Cardiothoracic Surgery, Oslo University Hospital Rikshospitalet, Oslo, Norway
  5. 5Department of Anesthesiology, Oslo University Hospital Rikshospitalet, Oslo, Norway
  6. 6Oslo University Hospital, Rikshospitalet, Oslo, Norway
  1. Correspondence to Dr Håvard Ravnestad; haarav{at}ous-hf.no

Abstract

Background Pulmonary endarterectomy (PEA) is the treatment of choice for chronic thromboembolic pulmonary hypertension (CTEPH), while balloon pulmonary angioplasty (BPA) is an alternative for inoperable patients. We aimed to compare right ventricular (RV) remodelling and late survival after PEA and BPA.

Methods In this prospective observational cohort study, we performed echocardiography at baseline and follow-up in patients with CTEPH treated with PEA (n=54) or BPA (n=44) between 2011 and 2022.

Results Follow-up echocardiography was performed at 5 months (IQR 4–7) after PEA and 3 months (IQR 2–4) after the last BPA. Both groups showed significant improvements in left ventricular end-systolic eccentricity index, RV basal diameter and RV fractional area change (RV FAC). Tricuspid regurgitation pressure decreased by 26±18 mm Hg after PEA and 13±21 mm Hg after BPA (p=0.02 for between-group difference). Tricuspid annular systolic excursion (TAPSE) decreased by 4±5 mm after PEA but increased by 1±4 mm after BPA (p<0.001). The TAPSE/systolic pulmonary artery pressure ratio improved similarly in both groups. Five-year survival was 96% (95% CI 86% to 99%) for PEA and 79% (95% CI 61% to 89%) for BPA (p=0.25). Change in RV FAC was an independent predictor of survival (HR 0.9, 95% CI 0.82 to 0.99, p=0.03).

Conclusions Both PEA and BPA led to significant RV reverse remodelling, with no clear evidence of a difference in survival rates. Improvement in RV function, particularly RV FAC, was associated with better outcomes, highlighting the importance of RV recovery in CTEPH treatment.

  • pulmonary arterial hypertension
  • pulmonary embolism
  • cardiac surgical procedures
  • treatment outcome

Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Data availability statement

All data relevant to the study are included in the article or uploaded as supplementary information.

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Footnotes

  • Presented at An abstract of this manuscript was presented at Heart Failure conference, 20–23 May 2023, in Prague, Czechia (Abstracts of the Heart Failure 2023 and the World Congress on Acute Heart Failure, 20–23 May 2023, Prague, Czechia. Eur J Heart Fail. 2023 Jul;25 Suppl 2:3-457. doi: 10.1002/ejhf.2927. PMID: 37415090).

  • Contributors HR is the guarantor for this manuscript. HR, AKA, KB and J-PEK produced the initial draft of the manuscript. KM, NM, RA, MS, EGj, SB, PSL, EGu and LG helped interpret the data and provided substantial revision of the manuscript. All authors have revised the manuscript, and have approved the final version.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests None declared.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.