Abstract
Pulmonary endarterectomy (PEA) is a potentially curative treatment for chronic thromboembolic pulmonary hypertension (CTEPH); however, decompensated right heart failure and concomitant cardiac procedures increase the risk of postoperative mortality. We report a case of operable CTEPH with severe mitral regurgitation causing right heart failure refractory to medical therapy. Emergent PEA combined with mitral valve plasty was considered unacceptably high risk. Although balloon pulmonary angioplasty (BPA) for CTEPH complicated by severe mitral regurgitation carries a risk of worsening pulmonary congestion, we assessed pulmonary artery wedge pressure by right heart catheterization and confirmed that it was not elevated after aggressive diuretic therapy. Therefore, a single BPA session was performed using undersized balloons, with treatment limited to a small number of lesions. This approach stabilized the patient's right heart failure without exacerbating pulmonary congestion and left-sided heart failure. Subsequently, elective PEA combined with mitral valve plasty was successfully performed, resulting in marked improvements in pulmonary hemodynamics and clinical symptoms. This case suggests that rescue BPA followed by elective PEA with mitral valve plasty may benefit selected patients with CTEPH complicated by severe mitral regurgitation and decompensated right heart failure refractory to medical therapy.