Upfront triple therapy with parenteral prostanoid as a bridge to balloon pulmonary angioplasty in severe chronic thromboembolic pulmonary hypertension

Balloon pulmonary angioplasty (BPA) has emerged as a new therapeutic approach for carefully selected patients with chronic thromboembolic pulmonary hypertension (CTEPH) [1]. Despite highly positive results, concerns have been raised about safety of BPA [2]. The most frequent BPA-related complication is lung injury, which is considered a consequence of mechanical vascular injury during wire manipulation or balloon overdilation [2]. Haemodynamic severity is associated with a higher rate of BPA-related lung injury [2, 3], and improving haemodynamics with pulmonary hypertension (PH)-targeted treatments prior to angioplasty may reduce this risk. In a recent study of CTEPH patients with moderate haemodynamic impairment, those who received the guanylate cyclase stimulator riociguat prior to angioplasty had fewer BPA-related serious adverse events than those who did not [4]. However, how to manage PH-targeted therapies in patients with very severe CTEPH to reduce the risk of BPA-related adverse events remains unresolved. Footnotes This manuscript has recently been accepted for publication in the ERJ Open Research . It is published here in its accepted form prior to copyediting and typesetting by our production team. After these production processes are complete and the authors have approved the resulting proofs, the article will move to the latest issue of the ERJOR online. Please open or download the PDF to view this article. Conflict of interest: The authors have nothing to disclose.