Rescue balloon pulmonary angioplasty in patients with low cardiac output syndrome due to chronic thromboembolic pulmonary hypertension: A case series

Balloon pulmonary angioplasty (BPA) is an effective treatment for patients with chronic thromboembolic pulmonary hypertension (CTEPH) who are ineligible for pulmonary endarterectomy. However, the treatment approach for patients with cardiogenic shock or refractory heart failure due to low cardiac output syndrome (LCOS) remains unclear, with limited studies on the efficacy and safety of rescue BPA in this population. Between 2011 and 2023, we performed rescue BPA on nine patients with CTEPH: two experienced severe CTEPH requiring extracorporeal membrane oxygenation or ventilator support due to complications from acute pulmonary embolism. Three had progressively worsening or drug-resistant right heart failure, three had syncope, and one had frequent ventricular tachycardia. Prior to BPA, cardiac indexes were below 2.0 L/min/m² without mechanical and inotropic support, and symptoms were likely related to LCOS. Although one patient died following BPA, the others experienced immediate hemodynamic improvements after the first BPA and were discharged alive. Rescue BPA may be a safe and effective treatment option for hemodynamically compromised patients with CTEPH and concomitant LCOS.

Learning objectives

Rescue balloon pulmonary angioplasty (BPA) improves hemodynamics and facilitates the withdrawal of mechanical and inotropic support for cardiogenic shock or worsening right heart failure in patients with chronic thromboembolic pulmonary hypertension. Rescue BPA may be a viable treatment option for hemodynamically compromised patients due to low cardiac output syndrome. However, given that these patients are at higher risk for complications, rescue BPA should be performed in specialized centers.