Riociguat pretreatment in patients with chronic thromboembolic pulmonary hypertension

Question Whether pretreatment with vasodilators reduces balloon pulmonary angioplasty (BPA)-related complications and achieves better outcomes in patients with inoperable chronic thromboembolic pulmonary hypertension (CTEPH) is unknown. We evaluated the effects of riociguat pretreatment on BPA-related complications and outcomes in patients with inoperable CTEPH. Patients and Methods We retrospectively identified 242 patients with CTEPH who underwent BPA between May 2014 and December 2022. Patients were subdivided according to the presence or absence of riociguat pretreatment, procedure-related complications, and overall survival. Results After baseline haemodynamic evaluation, 52 patients (21%) received riociguat prior to BPA (median dose, 6.0 [4.5–7.5] mg), while the remaining 190 patients (79%) underwent BPA as first-line treatment. At diagnosis, the mean pulmonary arterial pressure (PAP) and pulmonary vascular resistance (PVR) were similar between the groups, whereas the riociguat pretreatment group showed a lower mean PAP and PVR at the first BPA session. The prevalence of serious BPA-related complications throughout all BPA procedures was similar in both groups. After a median of four BPA sessions, improvements in haemodynamic parameters were comparable between the groups. During a median follow-up period of 76 months (interquartile range: 48–106) after BPA, 32 patients experienced all-cause death, and riociguat pretreatment did not influence survival (hazard ratio: 0.86, 95% confidence interval: 0.33–2.25). Conclusions Pretreatment with riociguat was not associated with risk reduction or overall survival after BPA. In patients with inoperable CTEPH who consider undergoing BPA, riociguat pretreatment is not mandatory for risk reduction.