Invasive Management for Acute-on-Chronic Thromboembolic Pulmonary Hypertension: Feasibility and Clinical Outcomes in a Single-Center Cohort

Jun Yamashita, Ryosuke Ito, Sayo Ikeda, Koki Hasegawa, Yoshikazu Takeuchi, Tomohiro Kasahara, Naotaka Murata, Shun Suzuki, Hideaki Kanazawa, Yusuke Shimahara, Kazuhiro Satomi

https://doi.org/10.1002/pul2.70407 

Abstract

Acute-on-chronic thromboembolic pulmonary hypertension (acute-on-CTEPH) is associated with rapid clinical deterioration, yet the role of invasive intervention in the acute phase remains poorly defined. We retrospectively analyzed consecutive patients with acute-on-CTEPH presenting with severe hypoxemia and/or cardiogenic shock at a single center between 2023 and 2026. Acute-on-CTEPH was defined as acute clinical deterioration requiring ventilatory or circulatory support, including ECMO, with imaging evidence of chronic thromboembolic disease and superimposed acute thrombi. Invasive strategies included pulmonary endarterectomy (PEA) and/or balloon pulmonary angioplasty (BPA), selected based on multidisciplinary assessment. The primary outcome was change in pulmonary hemodynamics; secondary outcomes included acute-phase mortality and clinical recovery after stabilization. A total of 15 patients (median age 69 years; 53% male), all in World Health Organization functional class IV, were included. Mechanical ventilation and ECMO were required in 53% and 47% of patients, respectively. Initial treatment consisted of PEA (40%) or BPA (60%), with combined approaches in selected cases. Acute-phase mortality was 20%. Among survivors, mean pulmonary artery pressure decreased from 42 to 17 mmHg, pulmonary vascular resistance from 11.6 to 2.4 WU, and cardiac index increased from 1.7 to 2.7 L/min/m2. Among patients requiring ECMO, 5 were successfully weaned and 4 survived to discharge. At follow-up, 11 of the 12 survivors were in WHO functional class I or II, and 8 (67%) had discontinued home oxygen therapy. Despite substantial acute-phase mortality, invasive strategies were associated with marked hemodynamic improvement and may represent a potential therapeutic option in this life-threatening clinical setting.

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