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TRANSCRIPT
19/15/2018
Presentation Sponsor: Charles B. Ross, M.D., F.A.C.S.
Piedmont Heart and Vascular Institute
Piedmont Atlanta Hospital
Atlanta, Georgia
Current Outcomes of Management of Massive Pulmonary Embolism Achieved by a Multidisciplinary Pulmonary Embolism Response
Team in a Quaternary Referral Center
Caroline G. Smith, B.A.Charles Ross, M.D., Eyal Ben Arie, M.D., Andrew Unzeitig, M.D., Veer Chahwala, M.D.
Andrew Klein, M.D., Prashant Kaul, M.D., David Kandzari, M.D.Chad Miller, M.D., Chad Case, M.D, Alexander Gluzman, M.D., Craig Patterson, M.D., Sean Sue, M.D.
David Dean, M.D.,Peter Barrett, M.D., Federico Milla, M.D., Morris Brown, M.D., John Gott, M.D., James Kauten, M.D.Grant Reynolds, B.S., E.M.T.
6th Annual Scientific SessionsGeorgia Vascular SocietyReynolds Plantation, Lake Oconee
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DisclosuresCharles B. Ross, M.D., F.A.C.S.
Consultant EKOS/BTG Corp
Board of Directors (2016 – 10/2019)
Developing a PERT4/13/2018
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Massive PE Outcomes
Pulmonary Embolism – Scope of the Problem
Courtesy of Fred Milla, M.D.PAH PERT August 31, 2018
150,000 to 250,000 hospitalizations per year60,000 to 100,000 deaths/ yearThird-leading cause of cardiovascular death- 25 – 33% present as sudden death- incidence is likely underestimated- 4% incidence of CTEPHSentinel event in any patient’s life
PE
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IntermediateRisk - 25%
HIGH5%
Low Risk70%
Large Thrombus Burden PE 2018: Risk for PE-Related Death
Standard VTE management
PE patients who manifest evidence for right heart failure
- time-critical decisions- multiple treatment options- absence of level I evidence
guiding management
May benefit from PERTmanagement
Massive PE Outcomes
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Essence of the PERT Approach to care for High-Risk PE
“bringing order to chaos”
Massive PE Outcomes
Pulmonary embolism response teams bring order to chaos- structured, algorithmic (but not inflexible) approach- collaborative decision-making - routine marshalling of resources and readiness for action- regular meetings
- volume review- discussion of care delivery issues- discussion of new techniques and incorporation- M &M
- review of post-discharge care
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PAH PERT
Massive PE Outcomes
PAH PE Program 2012:
Vascular SurgeryPulmonary – Critical Care
MedicineCT Surgery
ECMO Team
PAH Multidisciplinary PERT 2014-2018Leader – Dr. Charles Ross, MDED – Dr. Sean Sue, MDPulm-CCM - GLA Critical Care MD and APP staffInterventional Card – Drs. Klein, Kaul, and KandzariVasc/Endovasc Surg – Drs. Ross, Ben-Arie, Unzeitig, and ChahwalaCV – ICU/ECMO – Dr. BarrettCT Surgery – Dr. Milla (champion) & staffHematology – Dr. Jonas & partnersAPPs – GLA, CCU, VascularNursing – 4 East ICU, CCU, & CVCULevel I Coordinator – Grant ReynoldsDecision Support – Mike LunneyCath lab/IR/OR Staff
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The PAH PERT’s Approach
1. ED and P-CCM see first
2. Submassive PE patients are initially managed by P-CCM and call PE interventionalist
3. Massive PE patients- prompt conference call
- P-CCM- PE interventionalist- CT surgery- ECMO team
- prompt care plan- prompt response
Massive PE Outcomes
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76
87 7
10
5
14 14 1413 13
1716
17
9
4
23
1
2
1
21
23
2
1
2
2
0
2
4
6
8
10
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18
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Q3 2014 Q4 2014 Q1 2015 Q2 2015 Q3 2015 Q4 2015 Q1 2016 Q2 2016 Q3 2016 Q4 2016 Q1 2017 Q2 2017 Q3 2017 Q4 2017 Q1 2018 Q2 2018 Q3 2018
Quarterly PERT ActivationsJuly 2014-August 2018
Submassive PE Massive PE
Massive PE Outcomes
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Massive PE Outcomes
Massive Pulmonary Embolism – Definition
• Acute PE in the presence of hypotension
• SBP < than 90 mmHg for > 15 minutes
• SBP 40 mmHg less than baseline
• Vasopressor support required to maintain
• SBP > 90 mmHg
- 90 day mortality > than 15% and as high as 80%
PAH PERT Experience with Massive PE
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Massive PE Outcomes
Purpose:
Review the PAH PERT experience with massive PE
• Retrospective review of a prospective database
• Documented PE
• 7/2014 – 7/2018
Evaluate management strategies
Outcomes
PAH PERT Experience with Massive PE
3 minute response
target
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Massive PE Outcomes
PAH PERT Experience with Massive PE
Age:
• Mean: 57.7
• Median: 59.5
Patient Population:
Gender:
• 50% male
• 50% female
Comorbidity Percentage of Patients
Previously healthy 3.85%
BMI > 24.9 (normal) 88.46%
BMI > 30 (obese) 69.23%
Pre-existing cardiopulmonary disease 3.85%
Active neoplastic disease 15.38%
Recent surgery or trauma 46.15%
Comorbidities:
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Massive PE Outcomes
Total Reviewed Population =
28 Patients
Population analyzed =
26 Patients
Excluded patients =
2 Patients
PAH PERT Experience with Massive PE
*Excluded patients presented either with CPR
in progress or had palliative care initiated upon arrival
at PAH
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Massive PE Outcomes
PAH PERT Experience with Massive PE
Patient PresentationSYNCOPE CPR PRIOR TO
INTERVENTIONCPR AT ANY
POINTPRESSOR SUPPORT
7 patients 11 patients 13 patients 25 patients
27% 42% 50% 96%
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Massive PE Outcomes
PAH PERT Experience with Massive PE
Definitive Management
Number of patients
Number survived Percent survival Overall length of stay (days)
Length of stay of survivors (days)
Systemic thrombolysis
4 2 50.0% 4.25 7.00
UA-CDT (ECMO stand-by)
9 9 100.0% 11.22 11.22
Surgical Embolectomy
7 5 71.4% 13.14 15.80
VA-ECMO (only) 2 0 0.0% 5.00 N/A
VA-ECMO + UA-CDT
4 3 75.0% 28.00 33
All intervention 26 19 73.1% 12.77 15.42
Data and Outcomes:
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Massive PE Outcomes
PAH PERT Experience with Massive PE
Non-survivors
7 patients (26.9%)
Anoxic Brain Injury
2 patients (7.7%)
Persistent right ventricular failure with multi-system
organ failure
4 patients (15.4%)
Refractory cardiogenic shock
1 patient (3.8%)
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Massive PE Outcomes
SyncopeCPR Prior to Intervention
CPR at Any Point Pressor Support
Systemic Thrombolysis
100% survived1/1 patient
50% survived1/2 patients
50% survived1/2 patients
50% survived2/4 patients
UA-CDT 100% survived3/3 patients
100% survived3/3 patients
100% survived4/4 patients
100% survived8/8 patients
Surgical Embolectomy
100% survived1/1 patients
N/A0 patients
0% survived0/1 patient
71% survived5/7 patients
VA-ECMO 0% survived0/1 patient
0% survived0/2 patients
0% survived0/2 patients
0% survived0/2 patients
VA-ECMO + UA-CDT 100% survived1/1 patient
75% survived3/4 patients
75% survived3/4 patients
75% survived3/4 patients
Total 86% survived6/7 patients
64% survived7/11 patients
62% survived8/13 patients
72% survived18/25 patients
PAH PERT Experience with Massive PE
Survivorship by presentation and management
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Massive PE Outcomes
Evolution of Approaches to Massive PE
Survivorship Benchmarks
Massive PE Overall Mortality
ICOPER Registry Data
Massachusetts General Hospital
Piedmont Atlanta Hospital
58%
25%
27%
Goldhaber SZ, Visani L, De Rosa M. The Lancet. 1999; 353: 1386-1389
Kabrhel C, Rosovsky R, Channick R, et al. Chest. 2016;150: 384-393
Present series
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Massive PE Outcomes
Evolution of Approaches to Massive PE
Evolving use of VA-ECMO-Protocolized care
- Experienced VA-ECMO Center- VA-ECMO initiation (Ketamine)- Minimalization of mechanical ventilation- Aggressive and as early as possible
initiation of ECMO
In hospital survival: 97%One-year survival: 96%
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Massive PE Outcomes
Conclusion
In conclusion, massive PE has accounted for 13 percent of our PERT team activations
We have achieved a 73% survival rate using a flexible algorithmic approach, better than historic data and in line with contemporary data from other quaternary institution PERTs
National experience is evolving, however, from other centers of excellence suggesting that better results may be achieved through a more structured approach relying on broad and early utilization of mechanical circulatory support in massive PE
Our PERT is challenged by the proposition of escalating all massive PE cases to first-line mechanical circulatory support
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PAH PERT PE Interventionalists
Eyal Ben Arie, M.D.
David Kandzari, M.D. Drew Klein, M.D.
Charles Ross, M.D. Andrew Unzeitig, M.D.
Prashant Kaul, MD
Veer Chahwala, M.D.
Grant Reynolds, BS, RNCoordinator
Interspecialty Collaboration - PERTVAM 6/20/2018
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8
5
9
7 7
1
43
4 45
7
32
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8
2
1
1 1
3
1
1 1
1
1
12
3
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1
65
23
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4
1
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1 3
1
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5 5
2
1
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1 1
0
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Q3 2014 Q4 2014 Q1 2015 Q2 2015 Q3 2015 Q4 2015 Q1 2016 Q2 2016 Q3 2016 Q4 2016 Q1 2017 Q2 2017 Q3 2017 Q4 2017 Q1 2018 Q2 2018 Q3 2018
Quarterly PE Intervention by Physician
Charles Ross Eyal Ben-Arie Andrew Unzeitig Drew Klein Prashant Kaul Veer Chahwala
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Massive PE Outcomes