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

4

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

8

10

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

12

14

16

18

20

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

5

8

2

1

1 1

3

1

1 1

1

1

12

3

2

1

65

23

4

4

1

3

1 3

1

12

3

5 5

2

1

3

1 1

0

2

4

6

8

10

12

14

16

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