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Residual PH After PEA — EECC MCQ

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ModeratePulmonary Vascular DiseaseResidual PH After PEAEECC

A 70-year-old man with CTEPH has undergone successful PEA with normalisation of mPAP. At 6-month follow-up, he continues to have exertional dyspnoea and his mPAP has risen to 30 mmHg. What is this condition and management?

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Correct answer: E — Residual/recurrent PH after PEA — occurs in approximately 25-35% of patients; treatment options include BPA for accessible residual disease and riociguat (CHEST trial evidence) for medical therapy; lifelong anticoagulation continues

Residual or recurrent PH after PEA occurs in 25-35% of patients and reflects: (1) distal small-vessel pulmonary arteriopathy (beyond surgical reach); (2) incomplete endarterectomy of accessible disease; (3) recurrent thromboembolism. The 2022 ESC/ERS PH Guidelines recommend: (1) BPA for accessible residual disease (staged catheter-based balloon dilation — complementary to PEA); (2) riociguat (sGC stimulator) — the CHEST-1/CHEST-2 trials demonstrated improvement in exercise capacity and haemodynamics in inoperable CTEPH and residual PH post-PEA (Class I); (3) lifelong anticoagulation (prevents recurrent thromboembolism); (4) treatment at expert CTEPH centres. The multimodal CTEPH approach (PEA + BPA + riociguat) provides comprehensive management options for all disease patterns.

Reference: ESC/ERS (2022): PH Guidelines; CHEST Trials