Invasive Management for Acute-on-Chronic Thromboembolic Pulmonary Hypertension: Feasibility and Clinical Outcomes in a Single-Center Cohort.

Acute-on-chronic thromboembolic pulmonary hypertension (acute-on-CTEPH) is associated with rapid clinical deterioration, yet the role of invasive intervention in the acute phase remains poorly defined. We retrospectively analyzed consecutive patients with acute-on-CTEPH presenting with severe hypoxemia and/or cardiogenic shock at a single center between 2023 and 2026. Acute-on-CTEPH was defined as acute clinical deterioration requiring ventilatory or circulatory support, including ECMO, with imaging evidence of chronic thromboembolic disease and superimposed acute thrombi. Invasive strategies included pulmonary endarterectomy (PEA) and/or balloon pulmonary angioplasty (BPA), selected based on multidisciplinary assessment. The primary outcome was change in pulmonary hemodynamics; secondary outcomes included acute-phase mortality and clinical recovery after stabilization. A total of 15 patients (median age 69 years; 53% male), all in World Health Organization functional class IV, were included. Mechanical ventilation and ECMO were required in 53% and 47% of patients, respectively. Initial treatment consisted of PEA (40%) or BPA (60%), with combined approaches in selected cases. Acute-phase mortality was 20%. Among survivors, mean pulmonary artery pressure decreased from 42 to 17 mmHg, pulmonary vascular resistance from 11.6 to 2.4 WU, and cardiac index increased from 1.7 to 2.7 L/min/m