This document summarizes a presentation on pulmonary embolism given in 2014. It discusses various treatment options for pulmonary embolism including heparin alone, thrombolytics, surgical embolectomy, and catheter directed therapy. It notes that guidelines support thrombolysis for massive PE but are vague on submassive PE. One study showed thrombolysis for submassive PE led to a decrease in mortality but increase in major bleeding. The presentation emphasizes treating high risk PE aggressively with a multidisciplinary team approach and considering thrombolysis or advanced procedures to reduce long term morbidity. It describes the creation of a PE advanced care team at the hospital.
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CLOT Team Treatment of Sub-Massive and Massive PE
1. weill.cornell.edu
Oren Friedman MD, Pulm Crit Care
James Horowitz MD, Cardiology
Arash Salemi MD, Cardiac Surgery
Akhilesh Sista MD, Interventional Radiology
Surgery Grand Rounds
April 21, 2014
3. 34 F on OCP
Back pain and pleurisy
Normotensive, normoxic,
non distressed
CT bilateral
subsegmental PE
65 M out of
hospital cardiac
arrest ROSC
Massive RV
dilation, severe HD
instability
Recent intercranial
surgery =
Meningioma resection
• 68M CAD sp PCI
• 3 mo prior, DVT
• POD3 sp L4-5
laminectomy
• SOB, presyncope
O2 Sat 72% -> mid 80’s
on 6 L NC
• PE protocol CT showed
bilateral lobar
pulmonary emboli
• Vitals: HR: 120
BP=145/68
• Bedside echo: large
hypokinetic RV
8. weill.cornell.edu
1000 patients
IV Thrombolysis for Submassive PE led to a mild
decrease in death or hemodynamic instability mortality
Increase in Major bleeding in Thrombolytic Group
PEITHO Trial, 2014
9. weill.cornell.edu
Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International Cooperative
Pulmonary Embolism Registry (ICOPER). Lancet 1999; 353:1386–1389.
Fiumara K, Kucher N, Fanikos J, Goldhaber SZ. Predictors of major hemorrhage following thrombolysis for acute pulmonary
embolism. Am J Cardiol 2006; 97:127–129.
20 % incidence of major bleeding
3-5% risk of hemorrhagic stroke
*note: in ICOPER registry bleeding 24% in lysis , 15%
with heparin alone. ( common in both )
Why not lyse a pt with RVD
26. weill.cornell.edu
Pulmonary Embolism Advanced Care
• Multidisciplinary team consisting of Pulm/Crit Care,
Cardiology, Interventional Radiology and Cardiac
Surgery
• 24 hour pager x12568 (x1CLOT)
• Early Echocardiography
• Rapidly assess patients for high risk features
• Rapidly triage and mobilize services
• >100 consults in past 18 months at NYPH-WCMC
and HSS, and now transfers from network
hospitals
27. Heparin alone
Low bleeding
risk
Low Dose tPA vs
Catheter Directed
Lysis
*Looks Clinically Unstable, Poor Clinical Course, Worrisome Echo, Severe hypoxia, Syncope,
Elevated lactate, BNP/ Trop elevation, Large residual thrombus
Higher bleeding
risk
Catheter
Directed Lysis
Low bleeding
risk
Full dose tPA
Higher bleeding
risk
Catheter
Directed Lysis vs
Surgical
Embolectomy
Catheter Directed
Lysis vs Surgical
Embolectomy if
no improvement
PE Advanced Care: Protocol
28. weill.cornell.edu
• 68M CAD sp PCI, DVT 3 mo prior, tx with coumadin
• Prior to surgery, taken off ASA, plavix, coumadin
• POD3 sp L4-5 laminectomy, new SOB, dizziness.
O2 Sat 72% -> mid 80’s on 6 L NC
• PE protocol CT showed bilateral lobar pulmonary emboli
• Vitals: HR: 120, BP=145/68
• Bedside echo: large RV
PE post spine surgery
33. weill.cornell.edu
Pulmonary Embolism Advanced Care (1CLOT)
• High Risk PE’s are under recognized , under treated ,
and long term risks are under appreciated.
• We have created a multi disciplinary critical care
service bringing rapid appropriately aggressive care.
• Our internal algorithm is evolving in response to our
experience
• Very successful experience with catheter directed
lysis in submassive PE patients with high risk of
bleeding
• Multiple dramatic saves
• PERFECT registry, IRB for our WCMC registry
34. weill.cornell.edu
Works Cited
• Becattini C, Vedovati MC, Agnelli G . Prognostic value of troponins in acute pulmonary embolism: a meta-
analysis. Circulation. 2007; 116: 427–433
• Hsieh, p. Succesful resuscitation of acute massive pulmonary embolism with ECMO and open
embolectomy Ann Thoracic Surgery 2001;266-7
• Arcasoy, Selim, Kreit, J. “ Thrombolytic Therapy of Pulmonary embolism” Chest 1999
• Goldhaber SZ, Visani L, De Rosa M. Acute pulmonary embolism: clinical outcomes in the International
Cooperative Pulmonary Embolism Registry (ICOPER). Lancet 1999; 353:1386–1389.
• Fiumara K, Kucher N, Fanikos J, Goldhaber SZ. Predictors of major hemorrhage following thrombolysis for
acute pulmonary embolism. Am J Cardiol 2006; 97:127–129.
• Jaff MR, McMurtry S, Archer SL, et al. Management of massive and submassive pulmonary embolism,
iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: a scientific
statement from the American Heart Association. Circulation 2011, 123: 1788-1830
• Kearon C, Akl EA, Comerota AJ, et al. Antithrombotic therapy and prevention of thrombosis, 9th ed:
American College of Chest Physicians evidence-based clinical practice guidelines. Chest 2012;
141(2)(Suppl):e419S-e494SKuo, WT. Endovascular therapy for acute pulmonary embolism. J Vasc Interv
Radiol 2012; 23: 167-179
• Kasper W, Konstantinides S, Geibel A et al. Management strategies and determinants of outcome in acute
major pulmonary embolism: results of a multicenter registry. J. Am. Coll. Cardiol 30(5), 1165–1171 (1997). (
mappet trial)
• Kang. D. CT signs of right ventricular Dysfunction prognostic role in acute pulmonary embolism. JACC
cardiovascular imaging 2011;4(8):841-849
• Kearon C, Kahn KR, Agnelli G, Goldhaber SZ, Raskob GE, Comerota AJ. Antithrombotic therapy for venous
thromboembolic disease: American College of Chest Physicians evidence-based clinical practice guidelines
(8th Edition). Chest 2008; 133(Suppl):454S–545S.
• Lankeit M, Konstantinides S. “Mortality Risk Assessment and the Role of Thrombolysis in Pulmonary
Embolism” Clinics in Chest medicine 2010;31:759-769.
35. weill.cornell.edu
Works cited
• Leacche M, Unic D, Goldhaber SZ, Rawn JD, Aranki SF, Couper GS, Mihaljevic T, Rizzo RJ, Cohn LH, Aklog L,
Byrne JG. Modern surgical treatment of massive pulmonary embolism: results in 47 consecutive patients after
rapid diagnosis and aggressive surgical approach. J Thorac Cardiovasc Surg. 2005; 129: 1018–1023.
• Nijkeuter M, Hovens M, Resolution of Thromboemboli in patients with acute pulmonary embolism. A systematic
Review. Chest 2006
• Sharifi, M, Bay, Curt " Moderate Pulmonary Embolism Treated with Thrombolysis " AJCC in press
• Stevinson B, Hernandez-Nino “Echocardiographic and functional cardiopulmonary problems 6 months after first
time pulmonary embolism in previously healthy patients” J. Eur Heart Journal 2007; 28 2517 2524
• Wood K. Major Pulmonary embolism Review of a Pathophysiologic Approach to the Golden hour of
hemodynamically significant Pulmonary Embolism.” Chest2002.
Hinweis der Redaktion
A giant pe that kills our patient
6 died tpa 9 died heparin
stroke, 2.4% in tpa 1% in heparin m
major bleeidng 11.5% tpa heparin 2.4%
8 versus 25 decompensated ( heparin group)
8 versus 15 needed mechanical ventilation
1000 patient
criteria for enrollment dilated RV by echo OR positive troponin : approx 50% echo confirmed RVD
more patients in placebo group developed hypotension 8 in tenect 18
in placebo, needed vasopressors ( 5% versus 1.6% in teneceteplase)
CPR in placebo ( 5 arrests in placebo,1 in tenecta),
Intubation : 8 tenect needed intubation 15 in placebo,
major bleeding 11% in tenect , 2.4% in placebo : hemorrhagic stroke 2% tenect ( 10 patients ) ., and .2% in placebo ( 1 patient)
large retrospective series of 431 patients 30 day mortality was 15%in patients with RV enlargement defined as Rt/Lt ventricular dimentision ratio >.9 on CT
The RVD axial/LVD axial >1, RVD 4ch/ LVD 4ch >1 , and the RVV/ LVV >1.2 high sensitivity for predicting 30 d death .
Volmetric measurements had the highest predctor ( RVV/LVV >1.2 PPV of 30% for adverse outcome at 11% for death if you find this)
314 patients with acute PE, 81 excluded b.c of other dyspnea, copd, valcular disease, pulm htn
223 patients participated : 32 ( 14% ) had recurrent VTE during followup
patients with unexplained persistent DOE or rest then went TTE, then if positive VQ or pulmonary angiography
with measurement of PA pressure : CTPH present if systolic and mPAP >40 / >25 respectively. and normal PAOP
average length of anticoagulation was 1 year
excluded patients with history of other dyspnea/ pulmonary hypertension.
NOTE: only if they were symptomatic were they analyzed and worked up further: - and this was done in Italy where potentially
people are less likely to complain.
2009:
Both groups on average will show an improvement of RV over time. RV hypokinesis decreased from
20% to 7% of the heparin only group, and from 57% to 6% of the hep+TPA group.
half of those with elevated PA pressures in the heparin only group, had persistent or even HIGHER PA pressures on followup
when compared with heparin alone ; hep+TPA had significantly larger absolute median decrease in
RVSP ( -22 ) vs (-2)
Also a total of 24 of 93 patients ( 26%) from both groups had a repeat CTPA or VQ( one had vq) that
had unresolved filling defects, 37% of which had RVSP>40. All but one of these had been treated
with heparin alone. will have persistent pulmonary hypertension ( or worse pulmonary hypertension) , less residual clot, and it has a much more potent PA pressure lowering effect overall.
Details of study numbers Heparin only
RVSP initial; >40 in : 50 of 144 patient
followup: >40 mmHg:10 of 144
Out of those initial 50 : RVSP HIGHER on followup in 39 of 144 patients
and 18 of these had NYHA class 3 or 6 MWD <330
Heparin plus TPA
RVSP >40 :11 of 18 patients initial
RVSP >40 : 2 of 18 patients followup
nobody had increase in RVSP on followup
Kline article
200 patients
not randomized, these were just a group who got heparin only ,and heparin plus alteplase ( so obviously the alteplase group had worse baseline hemodynamics )
the RV hypokinesis ( function ) improved and mostly normalized in both groups
it was the RVSP that either didnt improve or worsened in 41% of the group with heparin alone ( about half of whom had dyspnea, exercise intolerance -- mostly in temrs of nyha score because there was no significance in 6mwd between groups)
121 patients with "moderate PE"
defined: CT evidence of >70% thrombus in >= 2 lobar or
left or right main PA, or by high prob va in >2 lobes
in this study no major or minor bleeding in any patients
594 patients from 35 studies met criteria for inclusion
Success rate 86.5%
Most common mechanical intervention was rotating pigtail ( 70% of the total study group) and alone in 53% of total group
Listed above are the patients getting extended and local infusions
The studies in which local or extended infusions of lytics were performed showed higher success than those with mechanical means alone
published 2005
47 patients
indications ; 45% contraindications to thrombolysis, failed thrombolysis 10% ; RVD 32%
12 of 47 in cardiogenic shock 6 of 47 in cardiac arrest
86% one year survival
5/6 out of the "late"deaths were from metastatic cancer
Massive:
PE with sustained hypotension
BP less than 90 for at least 15 m or requiring inotropes), pulselessness,
or persistent profound bradycardia