CLOT Team Treatment of Sub-Massive and Massive PE
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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
- 2. weill.cornell.edu Pulmonary Embolism in 2014 • This is what we’re afraid of
- 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
- 4. weill.cornell.edu Heparin Alone IV Systemic Thrombolytics Surgical Embolectomy Catheter Directed Therapy Options
- 5. weill.cornell.edu Jaff, Goldhaber, Kline Circulation 2011 Guidelines Support Thrombolysis for Massive PE but are purposely vague about Submassive PE
- 7. 30% normotensive patients have RVD 10% progressed to shock 5% in hospital mortality
- 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
- 10. weill.cornell.edu Why lyse a PE with RVD?RVD is not a hemodynamically “stable” situation
- 13. weill.cornell.edu If the predicted mortality from the PE exceeds the predicted mortality from Lysis…. Then you should lyse
- 15. weill.cornell.edu • Echo RV dysfn: 2.53 OR (Sanchez, Eur H J 2008) • RV/LV >0.9 predicts ICU (Araoz, Radiology 2007) BNP/n-proBNP: OR 9.5/5.7 (Sanchez) Elevated TnI: OR 5.9 (Becattini, Circ 2007) • CT : RV size
- 17. weill.cornell.edu Another reason to consider lysis? Risk of: • Chronic thromboembolic disease • Pulmonary HTN • Right heart failure • Exercise intolerance
- 19. weill.cornell.edu Will Lysing Their Clot Reduce Long Term Morbidity?
- 20. weill.cornell.edu Heparin + TPA Heparin Alone
- 22. In Select Patients Advanced Procedures are Preferable • Catheter Directed Therapy: – Mechanical Thrombectomy : maceration, aspiration, suction ( Angiovacc ) –Thrombolytic Infusion Catheters – Thrombolytic Infusion Catheters +Ultrasound Assist = Ekos • Surgical Thrombectomy • VA ECMO as bridge
- 23. weill.cornell.edu 594 patients 86% success rate. Major bleeding 2.5%
- 24. weill.cornell.edu Induction of anesthesia Heparinization during CPB Importance of proximal Clot Improvements in mortality
- 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