Balloon pulmonary angioplasty Dr Stephen Hoole, Interventional Cardiologist 5 th Annual Scientific Meeting Thursday 16 th March 2017 Museum of London Care | Valued | Excellence | Innovation
Overview • CTEPH unmet need for inoperable patients • Treatment algorithm • BPA • Procedural details • Our data in context • Possible complications Care | Valued | Excellence | Innovation
CTEPH – an unmet need Chronic thromboembolic pulmonary hypertension (CTEPH) • Persistent symptomatic pulmonary emboli at 1 year • Prevalence: 8 - 40 cases per million population • Mortality (untreated): 90% at 3 -years • Current treatments: Pulmonary endarterectomy (PEA) and medical therapy (pulmonary vasodilators, warfarin, LTOT) • 40% CTEPH patients are inoperable Care | Valued | Excellence | Innovation
CTEPH diagnosis: pulmonary hypertension with… Care | Valued | Excellence | Innovation
Treatment pathway • No impact on mortality • Expensive +++ • Improves Haemodynamics Morbidity and Mortality • Invasive +++ 60% 35% 5% Balloon Pulmonary Angioplasty Care | Valued | Excellence | Innovation
Balloon pulmonary angioplasty Care | Valued | Excellence | Innovation
Pulmonary angiogram guides treatment Care | Valued | Excellence | Innovation
Procedure details Anticoagulation stopped 5 days before – transitioned to LMWH stopped night before RFV 7 F Heparin 70 u/kg BPA performed under conscious sedation (2 hr procedure) Remifentanil (cough suppression) + midazolam Segmental 4 mm balloon / sub-segmental 2 mm balloon (balloon-to-artery ratio 0. 5 – 0. 8: 1. 0) ROS after 2 hrs when ACT<175 sec Bed rest 4 hrs Care | Valued | Excellence | Innovation
National BPA Service started on 2/10/15 Monthly BPA all-day list – treating 3 patients per list Care | Valued | Excellence | Innovation
A typical BPA case: RLL A 8 Pre Post Care | Valued | Excellence | Innovation
Initial Post-operative care ITU/ HDU Monitoring: ECG and Saturation monitor Post procedure CXR Recommence LMWH and warfarin or NOAC alone on evening of procedure Transfer to chest medical unit post-op day 1 -2 Monitor Saturations Creatinine Discharge home post-op day 3 -4 Care | Valued | Excellence | Innovation
Our first 48 procedures… • 16 patients treated with a median of 3 procedures each (range 1 – 6) Safety – 4 minor complications • 3 access site haematomas • 1 mild lung RI Efficacy – subjective symptomatic improvement and objective reduction in PVR* (-33. 5%, p<0. 001) and increase in 6 minute walk distance (+14. 2%, p=0. 05). Care | Valued | Excellence | Innovation
Comparison with other data Care | Valued | Excellence | Innovation
Reperfusion Oedema Segmental pulmonary oedema at day 0 -7 due to lung suddenly exposed to high pulmonary pressure Prevention Treatment - supportive Highest risk patients • 1 st procedure • High PVR > 1000 dyn·s/cm 5 • High m. PAP > 35 mm. Hg Optiflow Oxygen therapy Procedure staged in several sessions • 1 -2 sub-segmental arteries • Smaller balloon size (0. 5 -0. 8: 1 ratio) • Limit the volume of lung exposed to high m. PAP and endothelial shear force CPAP IV Steroids? Prostacyclin? Care | Valued | Excellence | Innovation
Pulmonary artery perforation Presentation (in lab) Treatment cascade Balloon tamponade Local contrast extravasation • Cough and haemoptysis • Hypoxaemia and shock Gel foam via a pulmonary artery microcatheter Pulmonary artery coil Protamine Intubation and ventilation Transfuse if Hb<80 g/L V-A ECMO Surgical repair Care | Valued | Excellence | Innovation
Right heart failure Presentation Treatment cascade Carefully consider fluid status Increase RV preload and EF vs. LV compression Titration of iv fluid/ diuretic carefully Good oxygenation Pulmonary vasodilator Inotropes Dobutamine Pulmonary vasodilators Hypotension Hypo-perfusion/ Oliguria Echo – RV dilatation, reversed IVC flow i. NO/ iloprost/ ET-1 antagonists/ PDE-5 antagonists Further BPA? Atrial septostomy/ R-P Impella / ECMO or RVAD HLT Care | Valued | Excellence | Innovation
Contrast Induced Nephropathy Presentation Treatment Definition: Prevention better than cure Increase in Cr >25% or 44 umol/L absolute increase at 72 hrs Minimise contrast dose Optimal hydration status Supportive Maintain fluid and electrolyte balance Severe cases may require renal replacement therapy Care | Valued | Excellence | Innovation
Funding for BPA Papworth Charitable funding for first 2 years • Approximately £ 2 -3, 000 per case if no major complications requiring ICU • Costs largely covered by pulmonary angio/ RHC tariff NICE appraisal on going National Commissioning decision awaited Care | Valued | Excellence | Innovation
The future… • Increase capacity after funding approved • Collect and publish data • Develop BPA technique e. g. day case • Understand intraoperative and post-op metrics of success e. g. RV function • European BPA working group (1 st BPA Meeting at European Heart House 13 th October 2016). • European Registry data and consensus statement on practice Care | Valued | Excellence | Innovation
The team Care | Valued | Excellence | Innovation
Further information Care | Valued | Excellence | Innovation
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