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Pulmonary Embolism Management A Comprehensive, Team Approach
David M. Dudzinski MD, FAHA, FACC
Northern New England ACC
November 14, 2015
No relevant financial disclosures
Agenda
• Pulmonary Embolism: Scope of the problem
• Treatment Options
• Description of a Pulmonary Embolism Response Team
• PERT Research: Advancing the Science of PE care
• Discussion
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Pulmonary Embolism: Scope of the Problem
3
5
VTE is Common
Am J Hematol. 2011;86:217-20
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2
PE Hospitalizations ↑ over time (adults ≥ 65)
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Am J Cardiol. 2015;116:1436.
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Virchow’s Triad 2015
Cleve Clin J Med 1999;66:113-23
STASIS Anesthesia
Hospitalization
Immobilization
HF/MI
CVA
Shock
Pregnancy
Obesity
VENOUS INJURY Surgery
Trauma
Prior DVT
Burns
Fracture
HYPERCOAGULABILITY Inherited Coagulopathy
Acquired Coagulopathy
Pregnancy/Parturition
Hormonal Therapy
Malignancy
INFLAMMATION
Pathophysiology of Pulmonary Embolism
Imaging Insights. 2011;2:705-715.
Eur Heart J. 2014;35:3033-69. 9
Pulmonary Embolism Types
MASSIVE
Shock /
Hypotension
LOW RISK
None of the
above
SUBMASSIVE
Normotensive
+ RV Strain
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Most Patients with PE do Well,
but some do not
Becattini C, Agnelli G. Predictors of mortality from pulmonary embolism and their
influence on clinical management. Thromb Haemost. 2008; 100(5): 747–751
Abrahams van-Doorn P. and Hartmann IJC. Imaging Insights. 2011; 2: 705-715 Dalen JE. Chest. 2002; 122: 1801-17
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Interim summary – Why care about PE?
• Common
• Acute mortality, long-term cardiopulmonary debility
• Tools exist for risk stratification
• Identifying patients at risk is not straightforward
• Treatment depends on proper patient identification
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3
Pulmonary Embolism: Treatment Options
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Therapeutic Alternatives in
Acute Venous Thromboembolism
Anticoagulation
• Unfractionated Heparin
• Continuous Intravenous
• Full-Dose Subcutaneous
• Low-Molecular-Weight Heparin
• Direct Thrombin Inhibitors
• Synthetic Pentasaccharide Xa Antagonist
• Warfarin Adjunctive Therapy • Vena Caval Filter
• Extracorporeal support
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Thrombolytic Therapy • Systemic
• Catheter Directed
• Pharmacomechanical
Catheter-Directed
Thrombolysis (PCDT)
Mechanical • Thromboaspiration
• Surgical Thrombectomy
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Guidance in the Literature for Treatment of
Massive/Submassive PE: Very Little
Circulation 2011;123:1788-830
Acute Massive/Submassive PE Therapy
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PEITHO: A 10 Year Trial to Finally
Answer the Question (?)
• Purpose:
– To investigate the benefit and safety of thrombolysis
(tenecteplase) versus placebo for normotensive patients with
intermediate risk PE.
• Randomized Trial
– Double blind
– Placebo controlled
– 1006 patients
N Engl J Med 2014;370:1402-1411
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PEITHO: Primary Outcome
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N Engl J Med 2014;370:1402-1411
4
PEITHO: Advantage driven by reduced
hemodynamic collapse
N Engl J Med 2014;370:1402-1411
PEITHO: No ∆ All Cause 30d Mortality
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N Engl J Med 2014;370:1402-1411
PEITHO: Safety Outcomes
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N Engl J Med 2014;370:1402-1411
• Single center open label, n=121
– “Moderate” PE: CT occlusion > 70% in main or ≥ 2
lobar arteries or high probability V/Q with mismatch in ≥
2 lobes (21% RV enlarge, 6% RV dysfunction)
• Efficacy: 2/3 less PH (and recurrent PE) at 28 months
• Safety: zero in-hospital bleed in both groups
Reduced Dose Systemic Thrombolysis:
? Dose of Lytics = Bleed Risk
Am J Cardiol 2013;11:273-277
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• Ultrasonic pressure waves emitted
along the catheter
• Lower drug dose (10-24 mg rt-PA)
delivered at 1-2 mg/hour
EKOS Thrombolysis
24 25
1.28
0.99 0.95
0.5
1.0
1.5
RV
/LV
Rat
io
EKOS+Heparin
1.20 1.17
0.98
Baseline 24 hrs 90 days Heparin
P<0.0001 P<0.0001 P=0.31 P<0.0001
ULTIMA: 59 patients randomized
RV/LV ratio (TTE)
Circulation 2014;129:479-486.
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Suction Embolectomy (Vortex)
• Rapid removal of clot
• Less invasive than surgery,
complications mostly
access related
• No large case series
• Resource intensive
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Surgery and PE: Original indication for CPB
• John H. Gibbon Jr.
– Surgical fellow at MGH
• October 3, 1930 bedside vigil as a young
woman died of PE following cholecystectomy
• Devoted his life to developing a machine to
assume the function of the heart and lungs
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• 47 patients undergoing acute
embolectomy over 5 year
period
• Indications:
-Contraindications to
thrombolysis (45%)
-Failed medical treatment
(10%)
-RV dysfunction (32%)
• 26% in cardiogenic shock,
11% in cardiac arrest
3 intraoperative deaths, 2/3
in cardiac arrest
JTCVS 2005;129:1018.
Surgical Embolectomy: Embolus in Transit
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Surgical Embolectomy (Acute)
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6
Pulmonary Artery Embolectomy
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Embolic Material
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But…challenges remain
• Patients in shock on presentation/transfer
• Recent (failed) lytics
• Peripheral emboli
• RV failure after surgical pulmonary embolectomy
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Current use of ECMO for PE
• Immediate support for PE patients in shock
– Prevent neurologic injury
• Postop support for RV failure after surgical embolectomy
• Peri-procedural support for suction embolectomy
• Preop support of patients that have received lytic therapy
• Support of patients with peripheral emboli
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Which therapy to use?
• Optimal treatment unknown: no standard approach or
“Appropriate Use Criteria” for intervention in PE
• Practice variations:
– Variation by medical specialty and attending, clot location
and size, threat to patient, etc.
▫ No accepted, standard algorithm
– No consistency in decision-making
– No single “team”
– No systematic evaluation of results
How do we (who?) decide whether, when, how, and for what
endpoint to intervene?
Description of the Pulmonary Embolism
Response Team
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PERT: Pulmonary Embolism Response Team
• Mission: Improve patient outcomes with a collaborative,
multidisciplinary team-based urgent consult to treat
submassive and massive PE
– Modeled on rapid-response and Heart team concepts
– Evaluate and offer full range of available treatments
– Multidisciplinary team of experts: convened via
electronic meeting → real-time decision for patient/MD
– (Scientific aims: data collection, care improvement) Dudzinski DM, Piazza G. Circulation (in press)
Provias T, Dudzinski DM, et al. Hosp Practice 2014;42:31.
MGH PERT. Chest 2013;144:1738.
ED / ICU / Floor Team
Pulmonary
Vascular Medicine/Cardiology Cardiac Surgery
Pulmonary Embolism Response Team (PERT)
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ED / ICU / Floor Team
Pulmonary
Vascular Medicine/Cardiology Cardiac Surgery
Pulmonary Embolism Response Team (PERT)
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Multidisciplinary Collaboration
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PERT
Vascular Medicine and Intervention Pulmonary/
Critical Care
Cardiac Surgery
Cardiac and Thoracic Imaging
Nursing
Quality & Safety Research
Echocardiography
Cardiology
Hematology/ Oncology
Emergency Medicine
PERT Program Flow Map
On Discharge:
Multidisciplinary
Follow-Up Clinic
ED
MGH
floor
OSH
PERT fellow:
History
Physical
Labs
EKG
Echo
CT-PE
Massive
Surgery
Vortex
ECMO
Lytic
Submassive CDT
Low Risk
Expeditious input and clinical judgment from
multiple specialties to optimize therapy
A/C
ACTIVATE PERT
MULTIDISCIPLINARY
TEAM
Electronic Meeting
Vascular Medicine
Cardiac Surgery
ICU/Pulmonary
Rad, Echo
Hematology
42
x11589
PERT Activation
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One telephone number
Answered 24/7 by the
MASCO answering service
• Follows documented protocol
• Fellow receives page that
includes a pre-defined set of
relevant information
• Administrator simultaneously
receives the same information
via email
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Multidisciplinary Virtual Consultation
Leveraging low-cost
internal and commercially
available tools
• Citrix® GoToMeeting
web-based videoconference
‒ Allows exchange of screen
control
‒ Tracks meeting date, time
and length
• Group email distribution lists
• Group paging
PERT Activation
44
PERT Activations
October 2012 Launch – present
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• Total activations: 498 ‒ ED: ~60%
‒ ICUs: ~20%
‒ Floors: ~20% (3/4 medical, 1/4 surgical)
• Multidisciplinary virtual consults: ~60%
‒ Median time to virtual consult: 108 min
‒ Number of participants: 8 – 15 physicians
‒ Average length of consult: 20-25 min
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AC Only
IVCF
IV Lysis
CDT
Vortex
ECMO
Surgery
MGH PERT: 10/2012-10/2015
• n = 498
• Male: 52% Female: 48%
• Age: median 62 yr (10 – 98)
• Interventions: 69.3% Anticoagulation only
15.1% IVC filter
4.5% Systemic thrombolysis
9.0% Catheter-directed thrombolysis
1.0% Large vessel aspiration
2.2% Mechanical support/ECMO
2.6% Surgery
• Survival to discharge: 86%
MGH PERT. Submitted data
• Continue multidisciplinary care for PERT inpatients
• First visit ~4-6 weeks after event
• Vascular Medicine/Intervention, Pulmonary, Hematology
• Case review 8am-9am, clinic 9am-12pm
– Discuss imaging, cancer screening, anticoagulation
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PERT Multidisciplinary Follow Up Clinic
PERT Research:
Advancing the Science of PE Care
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Operational Approach
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• 12 weeks
• 30 patients
‒ 25 confirmed PE
• Median time to PERT
meeting = 57 minutes
Chest. 2013 Nov;144(5):1738-9. doi: 10.1378/chest.13-1562.
A multidisciplinary pulmonary embolism response team.
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Operational Approach
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Operational Approach
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PERT Database
• Web-based
• Scalable
• HIPAA compliant
• Up to 347
variables
471+ patients, October 2012 through September 30, 2015
PERT Data
• Administrative patient
information
• Demographics
• Past Medical History
• Presenting symptoms and vitals
• Other active medical conditions
contributing to PE
• Symptoms
• PE diagnosis
• PE biomarkers
• Pre-PERT therapeutic
interventions
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• Information obtained following
PERT consult
• Follow-up: 24 hours
• Follow-up: 2-3 days
• Follow-up: 4-7 days
• Follow-up: 8-30 days
• Follow-up: 31-90 days
• Follow-up: 91-365 days
Current and Future Research Projects
• How does PERT affect treatment and outcomes?
• Do multidisciplinary meetings affect decision making?
• What are optimal methods of risk-stratification in PE?
• What is the incidence of CTEPH in patients with high-risk PE?
• When should patients with high-risk PE be screened for CTEPH?
• Does dual energy CT pulmonary angiography aid in the risk
stratification of high-risk PE?
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Ongoing Work on Prognostics
• Assessing RV strain by CT in addition to TTE
• Assessing PE severity by CT measure of aggregate clot
burden
• Additional EKG & TTE based parameters
Dudzinski DM…Kabhrel C. SAEM 2015;22:S112.
Praveen H, Dudzinski DM…Kabrhel C. In preparation
Praveen H, Dudzinski DM…Kabrhel C. Clin Cardiol 2015;38:236.
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Invited Presentations
• Dartmouth Hitchcock
• Washington University, St. Louis
• Bart’s Health, London
• American Thoracic Society
• Society for Thrombosis and Haemostasis
• American Heart Association
• VEITH Symposium
• CHEST National Meeting
• American College of Cardiology
• VIVA
• Local Meetings and Grand Rounds
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National PERT Consortium
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Launched May 2015
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MGH PERT Collaborators
Cardiothoracic Surgery
Thoralf M. Sundt III, MD
Echocardiography
David M. Dudzinski, MD
Emergency Medicine
Christopher Kabrhel, MD
Hematology
Rachel Rosovsky, MD
Pulmonary/Critical Care
Richard N. Channick, MD
Josanna Rodriguez-Lopez, MD
Radiology
Brian Ghoshhajra, MD
Vascular Medicine &
Intervention
Douglas E. Drachman, MD
Joseph M. Garasic, MD
Michael R. Jaff, DO
Kenneth Rosenfield, MD
Robert Schainfeld, DO
Ido Weinberg, MD
Pulmonary Embolism Management A Comprehensive, Team Approach
David M. Dudzinski MD, FAHA, FACC
@criticalecho
