Optical coherence tomography imaging of inoperable chronic thromboembolic pulmonary hypertension treated with refined balloon pulmonary angioplasty Article ID: AOP_14_088 ISSN: 1897-9483 Authors: Marek Roik, Dominik Wretowski, Andrzej Łabyk, Maciej Kostrubiec, Olgierd Rowiński, Piotr Pruszczyk Article type: Clinical image Received: October 27, 2014. Revision accepted: October 30, 2014. Published online: October 30, 2014. This article has been peer reviewed and published immediately upon acceptance. It is an open access article, which means that it can be downloaded, printed, and distributed freely, provided the work is properly cited. Articles in Polish Archives of Internal Medicine are listed in PubMed. Optical coherence tomography imaging of inoperable chronic thromboembolic pulmonary hypertension treated with refined balloon pulmonary angioplasty Marek Roik1*, Dominik Wretowski1, Andrzej Łabyk1, Maciej Kostrubiec1, Olgierd Rowiński2, Piotr Pruszczyk1 1 Department of Internal Medicine and Cardiology, Medical University of Warsaw, Poland 2 nd 2 Department of Clinical Radiology, Medical University of Warsaw, Poland * Correspondence to: Marek Roik, MD, PhD, Klinika Chorób Wewnętrznych i Kardiologii, Warszawski Uniwersytet Medyczny, Lindleya 4, 02-005 Warszawa, Poland Phone: (+4822) 502 11 44, fax (+4822) 502 13 63; email: [email protected] Chronic thromboembolic pulmonary hypertension (CTEPH) usually results from the chronic obstruction of the pulmonary arteries by unresolved thromboemboli following acute pulmonary embolism (PE). Surgical pulmonary endarterectomy is the first-line therapy in CTEPH, however some patients are inoperable due to high perioperative risk or distal localization of thrombi. Balloon pulmonary angioplasty (BPA), a new emerging therapy, with growing evidence has been adopted in this group of patients [1]. Recently refined BPA has been described with use of new imaging modalities, which markedly improved both BPA efficacy and safety [2,3]. Optical coherence tomography (OCT) is a novel, promising tool and was reported to be useful in the diagnosis and management of CTEPH [4]. Thus, we present a case of 80-year-old woman with CTEPH who was admitted for the next stage of refined BPA. The right heart catheterization confirmed severe pulmonary hypertension (mean PAP - 49 mmHg) and pulmonary angiography revealed distal CTEPH. To prevent severe complications (reperfusion pulmonary oedema or artery perforation) we performed OCT- guided refined BPA. Based on OCT measurements (lumen size, length of the lesion) and imaging (type of the lesions – webs, slits or ring like stenosis) – (figure 1 A,B,C), we used proper sized balloons (monorail balloon cathether, Pantera 3.5 x 15 mm, Biotronik). Furthermore three-dimensional OCT allowed to assess precisely the morphology of obstructive lesion of segmental pulmonary artery (figure 1D). We achieved very good final result of OCT-guided BPA (figure 1 – in the lower right corner). In-hospital course after BPA was uneventful and the patient was discharge home with improved functional capacity . OCT was very useful in precise localization and assessment of target lesions of pulmonary arteries (intravascular web, meshwork, slits). Moreover, OCT allowed to select the appropriate balloon size and length. Therefore, in our opinion OCT-guided BPA shows improved efficacy and safety, and we propose that OCT should be used routinely during BPA, however observation need to be confirmed in large studies. References 1. Sugimura K, Fukumoto Y, Satoh K, et al. Percutaneous transluminal pulmonary angioplasty markedly improves pulmonary hemodynamics and long-term prognosis in patients with chronic thromboembolic pulmonary hypertension. Circ J. 2012;76(2):485-8. 2. Mizoguchi H, Ogawa A, Munemasa M, Mikouchi H, Ito H, Matsubara H. Refined balloon pulmonary angioplasty for inoperable patients with chronic thromboembolic pulmonary hypertension. Circ Cardiovasc Interv. 2012;5(6):748-55. 3. Roik M, Wretowski D, Łabyk A, et.al. Refined balloon pulmonary angioplasty in inoperable chronic thromboembolic pulmonary hypertension - A multi-modality approach to the treated lesion. Int J Cardiol. 2014;doi: 10.1016/j.ijcard.2014.09.051. 4. Tatebe S, Fukumoto Y, Sugimura K, et al. Optical coherence tomography as a novel diagnostic tool for distal type chronic thromboembolic pulmonary hypertension. Circ J. 2010;74(8):1742- 4. Figure 1. Optical coherence tomography (OCT) of the pulmonary arteries in a patient with CTEPH treated with balloon pulmonary angioplasty. A – The pulmonary artery with no lesion; B- luminal flaps (webs/meshwork) of segmental artery of the left lower lobe; Cthrombotic occlusion of the artery; D- three dimensional OCT of the lesion before BPA. In the lower right corner final angiographic result of BPA of left pulmonary artery. Please note marked improvement of peripheral blood flow distally to the treated lesion