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In patients with CTEPH, persistent pressure overload induces progressive right ventricular (RV) remodeling, including myocardial hypertrophy, ventricular dilatation, tricuspid regurgitation and early diastolic ventricular septal bowing.8 These morphologic changes result in RV dysfunction and subsequent RV failure, which are the most common causes of death in CTEPH patients. And it is well known that RV pressure overload affects left ventricular (LV) function by not only limiting LV preload but also the abnormal pressure interaction via the interventricular septum and the pericardium, known as ventricular interdependence, which results in impaired LV filling, a decrease in LV stroke volume, and ultimately low cardiac output (Figure).9–11 Therefore, improvement in RV function is one of the most important treatment goals for CTEPH patients. PEA has been shown to restore RV function and RV remodeling by an acute reduction in RV afterload on echocardiography and magnetic resonance imaging (MRI).12 BPA also improves RV volume, RV systolic function, RV dyssynchrony and interventricular septal bowing assessed by echocardiography and cardiac MRI.8,13 However, the effect of BPA hronic thromboembolic pulmonary hypertension (CTEPH) is a life-threatening condition characterized by the pulmonary vascular bed obstructed by organized thrombi, which leads to progressive right-sided heart failure and a poor prognosis if left untreated. Pulmonary endarterectomy (PEA) has been recommended as the only curative treatment of choice for eligible patients with CTEPH and should be considered as the first treatment option whenever possible.1,2 Successful PEA can dramatically improve the patient’s hemodynamics and prognosis.3 However, only a proportion of patients fulfill the criteria for PEA and medical treatment has been attempted in cases of inoperable distal-type CTEPH and of post-PEA residual PH with a distal lesion. The principal medical treatment for CTEPH consists of life-long anticoagulant therapy, oxygen supply and a pulmonary vasodilator such as the soluble guanylate cyclase agonist, riociguat.1 Recently, Japanese investigators have refined balloon pulmonary angioplasty (BPA) by using smaller balloons, by cautiously limiting the number of balloon inflations and by the use of intravascular imaging.4–7 And they have demonstrated significant improvement in both the hemodynamic and exercise capacity after BPA. BPA is rapidly gaining attention worldwide as an effective treatment option for distal-type CTEPH. C

circulation journal

Beneficial Therapeutic Effects of Balloon Pulmonary Angioplasty on Biventricular Function in Patients With Chronic Thromboembolic Pulmonary Hypertension