Long-term follow-up of hemodynamic changes between balloon pulmonary angioplasty with and without medical therapy

Background Medical therapy before balloon pulmonary angioplasty (BPA) is recommended for patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH) with high pulmonary vascular resistance (PVR) to optimise haemodynamics and reduce procedural complications. However, the long-term haemodynamic effects of medical therapy combined with BPA remain unclear. Purpose This study aimed to evaluate the haemodynamic changes between BPA alone and BPA combined with medication, as well as to assess the long-term haemodynamic effects following continued and withdrawal medication after BPA. Methods This retrospective cohort study included 362 patients with CTEPH who underwent BPA and follow-up right heart catheterization (RHC). Patients were categorised into two groups: BPA-only (n = 184) and BPA with PH medication (n = 178). If haemodynamic improvement was observed at the first follow-up after BPA, medication was discontinued at the discretion of the attending physician. The first follow-up after BPA was conducted, and RHC was performed annually to evaluate haemodynamics. Results Haemodynamic parameters significantly improved after BPA in both the BPA-only and BPA with medication groups. In terms of hemodynamics after BPA, PVR was significantly lower in the BPA with medication group than in the BPA-only group (3.7 ± 1.5 vs. 4.3 ± 2.0 Wood units, p < 0.001). Similarly, cardiac index was significantly higher in the BPA with medication group than in the BPA-only group (2.6 ± 0.6 vs. 2.4 ± 0.5 L/min/m², p < 0.001). The baseline-adjusted mean differences in changes from baseline to post-BPA between the two groups, estimated by analysis of covariance, demonstrated a significant reduction in PVR in the BPA with medication group compared to the BPA-only group (-1.1 [95%CI, -1.5 to -0.8] Wood units, p < 0.001), as well as a significant increase in cardiac index (0.38 [95%CI, 0.27 to 0.49] L/min/m², p < 0.001). The BPA with medication group was further categorised into two subgroups after BPA: continued medication group (n = 100) and withdrawal medication group (n = 78). The continued medication group showed no significant changes in PVR or cardiac index over the two years. However, the withdrawal medication group showed a significant increase in PVR compared with the continued medication group (mean difference, 0.61 [95% CI, 0.12 to 0.78] Wood units, p < 0.001) and a significant decrease in cardiac index (mean difference, -0.51 [95% CI, -0.67 to -0.22] L/min/m², p < 0.001). Conclusion These findings suggest that while BPA alone provides haemodynamic improvement, continued PH medication may be beneficial in maintaining long-term haemodynamic stability.