Exercise Stress Echocardiographic Assessment of Exercise-Induced Pulmonary Hypertension in Patients with Chronic Thromboembolic Pulmonary Hypertension after Balloon Pulmonary Angioplasty.

Chronic thromboembolic pulmonary hypertension (CTEPH) may have residual pulmonary vascular dysfunction despite successful balloon pulmonary angioplasty (BPA). Although exercise-induced pulmonary hypertension is conventionally assessed by invasive right heart catheterization (RHC), exercise stress echocardiography may provide a noninvasive adjunctive approach. This study aimed to evaluate whether exercise stress echocardiography can assess pulmonary hemodynamic responses and identify residual exercise-induced pulmonary hypertension after BPA in patients with CTEPH. We analyzed 20 patients with CTEPH who underwent BPA followed by exercise stress echocardiography between June 2024 and March 2026. Exercise-induced pulmonary hypertension was assessed using the slope of mean tricuspid regurgitation pressure gradient to cardiac output between rest and peak exercise. Associations between exercise echocardiographic parameters and resting mean pulmonary arterial pressure measured by RHC were evaluated. Mean tricuspid regurgitation pressure gradient and cardiac output increased from rest to peak exercise (13.9 ± 7.3 to 31.6 ± 11.6 mmHg, p <0.001; and 4.3 ± 1.2 to 8.5 ± 2.3 L/min, p <0.001). Echo-based exercise-induced pulmonary hypertension, defined as a mean tricuspid regurgitation pressure gradient/cardiac output slope >3 mmHg/L/min, was present in 16 patients (80%). These patients had higher resting mean pulmonary arterial pressure than those without it (22 [19-27.8] mmHg vs. 18 [16-18] mmHg, p=0.047). In conclusion, exercise stress echocardiography characterized pulmonary hemodynamic responses after BPA in patients with CTEPH, suggesting potential value for assessing persistent pulmonary vascular dysfunction after BPA.