BACKGROUND: Chronic thromboembolic pulmonary hypertension results from mechanical obstruction of major pulmonary artery lumina with fibrotic tissue. Main treatment has been pulmonary endarterectomy, a complex surgical procedure removing vascular obstruction. However, at least 40% of patients are not candidates for pulmonary endarterectomy because of technical inoperability, comorbidities, or limited access to surgery. Balloon pulmonary angioplasty (BPA) has emerged as an interventional treatment for these patients. OBJECTIVES: The International BPA Registry (NCT03245268) was designed to investigate BPA practice across 18 established centers in the United States, Europe, and Japan. METHODS: A total of 500 patients were prospectively and consecutively enrolled between March 2018 and March 2020, with follow-up until March 2022. Of these, 484 patients were included in the analysis set. RESULTS: Regional differences were seen in patient characteristics (fewer patients with prior pulmonary endarterectomy and more elderly women in Japan) and procedural details (less medical pretreatment, more jugular access, more segments and more occlusive lesions treated per session and patient, less conscious sedation, less contrast and less radiation, shorter intervals between BPA sessions in Japan). Female sex, procedure in Europe/United States, pulmonary hypertension medications at any time, and higher baseline pulmonary vascular resistance (PVR), calculated as transpulmonary pressure gradient divided by cardiac output, emerged as independent predictors of complications during BPA. After a median of 5 (Q1-Q3: 3-6) BPA sessions per patient within a median time of 4.9 months (Q1-Q3: 1.7-11.0 months), a 15-mm Hg (38%) decrease in mPAP, a 332 dynes/s/cm-5 (57%) decrease in PVR, and a 3.2% increase in arterial saturation (medians; P < 0.001) were observed, and there were significant improvements in functional class, 6-minute walk distance, serum levels of N-terminal probrain natriuretic peptide, and Borg dyspnea index. BPA complications occurred in 11.3% of sessions and 33.9% of patients and were mostly hemoptyses. No patient died within 30 days of BPA. CONCLUSIONS: Our data are in line with previous reports on changes of clinical and hemodynamic parameters and complication rates of BPA. Centers with more experience providing BPAs were more likely to achieve a higher percentage decrease in PVR.

Amsterdam UMC location Vrije Universiteit Amsterdam Department of Pulmonary Medicine and Amsterdam Cardiovascular Sciences Pulmonary Hypertension and Thrombosis Amsterdam the Netherlands

Assistance Publique Hôpitaux de Paris Department of Respiratory and Intensive Care Medicine Bicêtre Hospital University of Paris Saclay Le Kremlin Bicêtre France

Assistance Publique Hôpitaux de Paris Service de Pneumologie Hôpital Bicêtre Université Paris Sud Laboratoire d'Excellence en Recherche sur le Médicament et Innovation Thérapeutique and Institut National de la Santé et de la Recherche Médicale Unité 999 Le Kremlin Bicêtre France

Clinical Dept of Respiratory Diseases University Hospitals of Leuven and Laboratory of Respiratory Diseases and Thoracic Surgery KU Leuven University of Leuven Leuven Belgium

Department of Cardiology NHO Okayama Medical Center Okayama Japan

Department of Cardiology Pôle Thorax et Vaisseaux CHU Grenoble Alpes La Tronche France

Department of Cardiovascular Diseases Temple University Hospital Philadelphia USA

Department of Cardiovascular Medicine Mayo Clinic College of Medicine Rochester Minnesota USA

Department of Internal Medicine 2 Division of Cardiology Medical University of Vienna Vienna Austria

Department of Interventional Radiology Marie Lannelongue Hospital Paris Saclay University Le Plessis Robinson France

Department of Pulmonary Circulation Thromboembolic Diseases and Cardiology Centre of Postgraduate Medical Education European Health Centre Otwock Poland

Department of Thoracic and Vascular Surgery and Heart Lung Transplantation Marie Lannelongue Hospital Paris Saclay University Le Plessis Robinson France

Department of Thoracic Surgery Kerckhoff Heart and Lung Center Bad Nauheim Germany

Division of Cardiovascular and Thoracic Surgery University of California San Diego La Jolla California USA

Division of Cardiovascular Medicine University of California San Diego La Jolla California USA

Division of Pulmonary and Critical Care Massachusetts General Hospital Boston Massachusetts USA

Division of Pulmonary Circulation Department of Cardiovascular Medicine National Cerebral and Cardiovascular Center Osaka Japan

Division of Pulmonary Critical Care and Sleep Medicine University of California San Diego La Jolla California USA

Division of Pulmonary Medicine Cleveland Clinic Cleveland Ohio USA

General University Hospital Prague Czech Republic

Health Management Center Iruma Heart Hospital Iruma Saitama Japan

Royal Papworth Hospital Cambridge United Kingdom

School of Allied Health Sciences University of Suffolk Ipswich United Kingdom

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