Although the prognosis of chronic thromboembolic pulmonary hypertension (CTEPH) is poor, its survival has been improved by thromboendarterectomy surgery and balloon pulmonary angioplasty (BPA). Clinical practice guidelines1 and consensus documents2 state that BPA should be performed in high-volume expert centers to guarantee good outcomes and a low rate of complications. In Spain, these criteria are met by just 2 expert centers, services, and units (RCSUs), designated in 2015 by the Spanish Ministry of Health for this disease.3 The objective of this designation is to guarantee equitable access and high-quality, safe, and efficient care for patients with diseases requiring a high level of specialized care and to therefore concentrate patients in a small number of centers. However, this situation needs to be reconsidered due to the growing demand for this procedure and long waiting times in the RCSUs, the increasing interest of non-RCSU centers in performing BPA, and the long distances travelled by patients from other autonomous communities to the RCSUs. In this regard, the consensus document of the European Respiratory Society proposes that BPA procedures be permitted in nonexpert centers, under the guidance of an expert center.4 Here, we present the results of a pioneering experience that includes the performance of BPA in nonexpert centers through a network protocol coordinated with a referral RCSU.

The multidisciplinary CTEPH unit in our RCSU has been a pioneer in Spain in the teaching of the BPA procedure via theoretical and practical courses and training stays in the unit. In addition, a collaborative network program was developed with centers that refer patients to our RCSU and would like to begin conducting BPA in order to enable the referring centers to autonomously perform BPA after a training period overseen by our RCSU. The ultimate aim of this collaboration is to secure uniform therapeutic opportunities for patients with CTEPH, whether they are managed in referring centers or in the RCSU, and to guarantee high-quality and safe treatments. Accordingly, we developed a protocol-based collaborative network program (table 1). The main prerequisite of this program is that all patients be presented in a multidisciplinary session in the RCSU to determine each patient's optimal therapy. If BPA is chosen, any low- or intermediate-risk procedures can be performed in the referring centers after a period of guided training (figure 1). A second precondition of the program is that the “nonexpert” center be equipped with a pulmonary hypertension unit experienced in the diagnosis and pharmacological management of pulmonary hypertension, including the use of drugs with complex administration protocols, as well as experience with the intensive care management of possible BPA-associated complications.

Figure 1.

Pulmonary angioplasty network program. BPA, balloon pulmonary angioplasty; CTEPH, chronic thromboembolic pulmonary hypertension; RCSUs, expert centers, services, and units; TEA, thromboendarterectomy.

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Currently, this BPA program in referring centers and coordinated with the RCSU is in operation in 3 centers in autonomous communities distinct from that of our RCSU. Interventional cardiologists in these centers underwent a theoretical/practical course on BPA in our RCSU, conducted the first 10 BPA procedures in their centers under the guidance of an interventional cardiologist from the RCSU, and now independently perform low- and intermediate-risk procedures in their centers. The present work has been conducted in accordance with international recommendations on clinical research and has been approved by the ethics committee of our center. Informed consent was obtained from all patients and stored.

All patients included in this BPA network program were presented in a multidisciplinary CTEPH session in our RCSU in which the appropriate therapeutic option was selected for each patient in conjunction with the referring physicians. The first procedures were performed in our RCSU for high-risk patients or those with elevated technical complexity, so that 13 of the 63 procedures were performed in the RCSU while the remainder were performed in the referring centers (figure 1). The results of this program are shown in table 1. The data show similar clinical, hemodynamic, and biomarker improvements to those published for the first 46 patients who underwent BPA in our RCSU.5 The periprocedural complication rate in the referring centers was also similar to or lower than that described for our RCSU series.5 All complications were mild (table 1), with no periprocedural deaths, confirming that the network BPA program is safe for patients.

In conclusion, the preliminary results indicate the feasibility of this novel network protocol for CTEPH, which includes the performance of pulmonary angioplasty in nonexpert centers and conducted in a network coordinated with the referral RCSU for low- and intermediate-risk patients. The preliminary results demonstrate that this approach could be safe and effective. This type of tutored pulmonary angioplasty program in referring centers would additionally reduce procedural delays and improve the efficient management of this disease.