Letter to the Editor Refined balloon pulmonary angioplasty in inoperable chronic thromboembolic pulmonary hypertension — A multi-modality approach to the treated lesion Marek Roik a, ⁎, Dominik Wretowski a , Olgierd Rowiński b , Andrzej Łabyk a , Maciej Kostrubiec a , Barbara Lichodziejewska a , Katarzyna Irzyk a , Olga Dzikowska-Diduch a , Sabina Zybińska a , Agnieszka Szramowska a , Piotr Pruszczyk a a Department of Internal Medicine and Cardiology, Medical University of Warsaw, Poland b 2nd Department of Clinical Radiology, Medical University of Warsaw, Poland article info Article history: Received 28 August 2014 Accepted 17 September 2014 Available online 28 September 2014 Keywords: Balloon pulmonary angioplasty Chronic thromboembolic pulmonary hypertension IVUS FFR Introduction. Chronic thromboembolic pulmonary hypertension (CTEPH) represents uncommon or under-diagnosed sequel of acute or chronic pulmonary embolism (PE). The gold standard therapy for CTEPH is pulmonary endarterectomy (PEA) which markedly improves the prognosis or even cures the disease in the majority of patients with CTEPH [1]. Nevertheless some CTEPH patients are not operable due to small-vessel disease (“distal CTEPH”) due to significant co- morbidities making the risk of surgery unacceptably high [2,3]. Thus, we present a case report of an inoperable patient with CTEPH who successfully underwent refined balloon pulmonary angioplasty (BPA) with multi-modality approach: intravascular ultrasound (IVUS) and fractional flow reserve (FFR) assessment to optimize clinical effect and to prevent the complications. Case report. 80-year-old woman with diagnosed severe distal CTEPH, on chronic oral anticoagulation due to acute deep vein thrombo- sis and intermediate risk PE in 2 years before she was admitted to our Department to perform BPA. On the admission she was in WHO class III/IV and with signs of right heart failure. The right heart catheterization confirmed severe pulmonary hypertension (mean PAP — 49 mm Hg, POAP — 8 mm Hg, PVR — 10.6 HRU) and pulmonary angiography revealed distal CTEPH. Based on age, co-morbidities and distal location of lesions the operative risk was deemed too high and the patient was annotated as inoperable by a PEA experienced cardiac surgeon. BPA was performed from the right jugular vein, with anticoagulation contin- ued with reduced intensity to maintain an INR in lower therapeutic range. For supra-selective angiography and to advance to target lesion we used telescopic technique: 6 F guiding catheter (MP1, Launcher, Medtronic) via the long sheath (Brite TIP, Cordis/Johnson and Johnson). Following administration of intravenous heparin 5000 IE (supplied with 2500 IE every 60 min if ACT was below 250) intravascular webs (Fig. 1A) were passed with 0.014″ pressure wire to measure to FFR ratio (FFR measurement allows in determining the ratio between pulmonary pres- sure in arteries distal to web stenosis and proximal pressure, PressureWireTMCertus FFR, St. Jude Medical) and IVUS catheter (Eagel Eye Platinum, Volcano, ChromaFlo Imaging) to measure the lumen di- ameter, length of stenosis and visualize organized thrombi and lumen (Fig. 1C,E). To prevent the occurrence of sever pulmonary injury we se- lect the undersized balloon (vessel diameter — 5.2 mm in IVUS), 80% of vessel diameter with additional 20% reduction of balloon size because of high mPAP (49 mm Hg) — as previously proposed by Mizoguchi H. and Matsubara H. [4]. After two balloon inflations (monorail balloon cathe- ter, Pantera 3,0 × 15 mm, Biotronik, pressure 7–8 atm. for 20 s) control angiography, IVUS and FFR were performed to assess to lumen diameter and pressure gradient. Control assessment showed better opacification of distal arteries in angiography, increased in minimal lumen diameter in IVUS (thrombi were compressed) and increased FFR ratio (from 0.5 to 0.71) — (Fig. 1D,F). Based on this multimodality approach and after final selective angiography we achieved a good final result of BPA (Fig. 1B). The post-BPA hospital course was uneventful (in chest-CT no pulmonary edema was observed) and the patient was discharged home with improved condition. Discussion. The long-term prognosis for patients with CTEPH without intervention is poor and depends on the degree of pulmonary arteries obstruction and right ventricular function [5]. PEA is recom- mended as the first line therapy for eligible patients with CTEPH and International Journal of Cardiology 177 (2014) e139–e141 ⁎ Corresponding author at: Department of Internal Medicine and Cardiology, Medical University of Warsaw, Lindleya 4, 02-005 Warsaw, Poland. Tel.: +48 22 502 11 44; fax: + 48 22 502 13 63. E-mail address: mroik@wum.edu.pl (M. Roik). http://dx.doi.org/10.1016/j.ijcard.2014.09.051 0167-5273/© 2014 Elsevier Ireland Ltd. All rights reserved. Contents lists available at ScienceDirect International Journal of Cardiology journal homepage: www.elsevier.com/locate/ijcard