Chapters Transcript Video Modern Perspectives in Pulmonary Embolism Management thank you very much for all of you guys that are here plus one. So I got asked to give a perspective in palmer embolism management today focused on sub massive. I've got 10 minutes to do it. So why not take a really hard conversation and make it longer and harder. This is about an hour and a half talk. Normally I have 157 slides. I thinned them down to 50 I'm not kidding. So we're going to do 50 slides in 10 minutes and try to stay on target and there's no timer. So cut me off in a minute. It really can be done that way. I've got some disclosures and the majority of them are that we're going all the trials here. So Sentara healthcare is in every pe trial except one right now in America, which is pretty spectacular, vascular surgery is running the trials here, which is novel cardiology and I are both have a giant stakeholder in this. We're at a heart meeting but VT kills more people than breast cancer, AIDS and car accidents combined. And it's a complicated thing to say out loud because everybody knows that breast cancer month. We wear pink ribbons and we have pink things on at football games and nobody has any idea that DVT awareness month is in March or the ribbon colors or that we have VT world awareness day and we do a really crappy job at preventing a mostly preventable disease and we spend billions and billions of dollars on treatment of it. So it's a big deal and it deserves a little bit of attention. This is the dunning Kruger effect. And you know, it's funny that Rich calls me an expert. I have no idea where I am on this right now. But when you show up out of training and you know everything dr v's who's my junior partner and just started with us. He's up here and maybe he's really over here because he went to the Cleveland clinic and way brighter. But I watched my collapse of intelligence hit somewhere around here this week and I don't know when I'll crawl out of the hole, but there's a lot of stuff we just don't know about this and the more we look, the more we realize we just don't know it. And by the way, this concept is not just really did win the Nobel prize and this is what medical education is all about. So we'll kind of go through PE in a nutshell. The well's criteria for DVT is well understood. But everybody who goes to the er with chest pain doesn't have a P. E. They might have a syndrome as we just heard, or they might just have, it hurts when you push on my chest. So, scanning the right people to find the right diseases important, their scores for it. PE is bad and pE is not bad because of hypoxia. I think most people think that pulmonary Eliza has caused you to stop breathing oxygen in and that's really not what happens. We're in a cardiology meeting. It really is a cardiac dominant idea of RV failure and RV failure ultimately leads to a lot of really bad things before shock and death. We sort of stratify pulmonary embolism into three major categories. Those that are going to kill you, those that aren't going to kill you and those that are in between those that are going to kill you are the ones over here in the massive population. They make up a very small proportion and these people look like they're going to die their hypotensive. They're on pressers. There are three month mortality is 60% and their chances of doing well if they're in the 40% is also fairly poor. Then there's these patients. This is a I've got a really expensive cat scanner and I find a lot of really small clots that's the miners. And those people can pretty much go home. We'll talk about that in a second. The ones you want me to talk about are these those patients that are somewhere in between. Those are the people that make up a good number of patients. They look okay from the door, but their ventricle doesn't squeeze, right? It's why getting echoes is so important and they've got a 25% mortality at three months. We have scoring systems that help us figure out who can go home. That is the pesky score on the left or the simplified or surgical Pepsi on the right. If you don't have enough points, you can probably go home. I'm going fast. But these scoring systems are all very readily available. The newest scoring system, probably the best is the bow of a score. And the reason why the bogus score is good is that it helps us determine who is sick enough to predict an outcome. So most pulmonary embolism scoring systems don't let us predict bad outcomes. And you can see whether your score one, score two or score three, you've got two points or less, three or four or more than four. More than four has a 40% risk of cardiovascular complications and the 10 day, 10% 1 month risk of death. These are the people that were obviously most interested in in down here, but even the three or four pointers have an 18% risk of complications and a 7% risk of death. So how do we figure this out from both? The score, We do a little bit of testing. So sita's for everybody, echoes for most everybody if they're stable and then some blood work. So, pro BNP and proponents are predictive factors that say your heart's not working quite right. Myoglobin and heart fatty acid binding deed Eimer while important to look at Claude and Claude burden may not predict mortality. However, a pro BNP, that's under 1000 nobody dies and the higher your troponin is, the more likely you are to die and your hazard ratio for troponin is being positive is 18. So a negative troponin means you're not going to die. A elevated troponin means you're 18 fold more likely to die and almost triple the hazard ratio of an elevated BNP echoes are interesting. Seti has tried to take over measurement of the right ventricle. It's best done on one trial, looking at all four quadrants in non axial views and doing reconstructions, nobody does that real time anywhere. It makes looking at the right heart on CT really really hard and this doesn't take into account how well the RV is actually functioning. So while you may be able to get an R. V. L. V ratio on cT scan, you can say very little about its function. We need treatment protocols and you can see on the right this is a cardiology meeting and we have really clean and easy stem e protocols. This is pulmonary embolism program. We have a reasonably similar one where the er does immediate testing patients get an immediate phone call through the page operator either to the shock team or the PE team. And there are things that are embedded into epic to allow us to do them. But it has to look reasonably streamlined the question that gets asked a lot and we're lucky at Sentara were part of an idea and we're also the referral hospital for two other systems regionally is can my hospital do this and the answer is at Norfolk where I'm lucky enough to work most of the time we can do pretty much everything. We've got 24 7 coverage of the ICU the Cath lab, the vascular lab, we've got cardiologist, pulmonologist and interventional ists who are all actively involved in this. And cardiac surgeons willing to rem move clot, unlimited notice. We don't have that most anywhere else. So based on how sick the patient is. The more Bova points they have with the higher the score, the more likely they are to need higher level resources. And you can almost invert Bova and lay this over this. That above a one can be done anywhere above A two can be seen at A level two or level three hospital and above A three which are the sickest patients do best when you have all the resources available. So looking at the pE algorithm itself will kind of make this reasonably simple, massive pes need blood thinners and an immediate management decision that can be either ivy throb Olynyk therapy. There's an epic order set for our system for that. It's either 100 over two hours or 50/2 hours. We've done some perc. Utan assemble ectomy is and we've done some open emb elect amis with the help of cardiac surgery over the last few years and it's sort of hard to figure out if one is better than the other because these people are sicker than stink and now we've been putting people on ECMO and talking about pulling Claude out with some semblance of rest. And they look about the same when you look at where our survival rates are. And these are actually better survival rates with open pulmonary and elected me on massive than the national standard. Minor pes are also really easy. They look fine from the door. They have low mortality rates, they get blood thinners. You can think about sending them home from the er and you only think about intervention if the patient gets worse and now onto the sub massive. These are the ones that are a little bit interesting. So the rationale for treating these people at all is that what we know is if you're right heart is dysfunctional. It's an independent predictor of mortality. You're four times more likely to die if you're right heart is dysfunctional when you're discharged and if it's back to normal and you're eight times more likely to have a pe recurrent and that's not that's just recurrence. Then if your R. V. Has gone back to normal at baseline. Hard to say who goes on to chronic thrombosis pulmonary hypertension but it's at least 3.5 to 4% and that's without invasive imaging. With invasive imaging. It's probably double that. So the reason why we should fix people is to prevent long term right heart strain and short term bad outcomes. A lot of small print and all this is readily available. The perc consortium is a group of hospitals across the country that look at the best way to treat these and these get updated year in and year out and we fall fairly in line with following the consortium's recommendations on who gets treatment and what treatments they get in terms of what treatments they can get. There's 1000 options. So you can put catheters into clot and you can melt clot with TPA. That's a catheter. This is a catheter is more modern. It gives side hold drips and then there's yet another one that can ultrasound enhance the TPA as it gets pushed out into clot. A lot of reasons to do it. But grossly IPA is IPA is IPA. Clot is made up of fiber and strands. Plasminogen is present in the clot. TPA activates plasminogen and then it degrades the clot. And this is the pretty picture in all of our nursing and doctoring textbooks on how works. Ultrasound enhancement will sometimes break up fiber and strands and can hurry up the process. And that's sort of the the the theory behind why an ultrasound enhanced something is used both in the arterial system for with a plastic that got talked about next door earlier or maybe using it in veins or clots to help absorb more T. P. A. There are mechanical devices that allow you to suck out clot. This is the indigo system by Penumbra. It's big, it's eight french and 12 french. So 3 to 5 millimeters. It has an FDA stamp to do this based on trials we were in this is the flow Trevor by an ari this can be as big as 24 french. That's eight millimeters. It can go into the lungs and also pull out clots. Also FDA approved. In terms of research data, we've been in the majority of the trials. So you want to make sure your clots are large enough to be causing the problem? The patient is there for Sorry friend. I'm on call. Sorry. When we talk about TPA for clot removal, what we know is that looking at individual studies, we can't figure out anything but circulation is nice enough to do a large meta analysis. And the long story, made very short by looking at a controlled randomized trials and meta analysis is that pop prevents death when mashing together massive and sub massive patients in massive it's very easy. The majority are going to die in sub massive is maybe the risk isn't worth the benefit. When you look at major bleeding rates and compare them to death rates and that's why thrombin has become a thing. When we look at all the research trials one by one with just one focus slide. They all do the same thing. They all improve the right ventricular ratio from being upside down greater than one to right side up, less than one at 24 hours. This is pa with an alternative hands. Catheter thrombin lex did the same thing. 1.5 to 2.97 at 24 or 48 hours. Flow Trevor mechanical from me did the same thing 1.5321 point 15 at 48 hours. They have a display a score as well and you can see that patients do feel better at a month, 30 day outcomes. Also with flow Trevor 1.252 point 83 for R V L. V ratios. This is the Penumbra trial, another trial we were part of and shows the exact same thing Again, a 43% improvement in RVL. V ratio. So no controlled randomized trials comparing devices but the idea of early improvement of RV function is very clear. These are the ongoing trials. Strike PE is a single arm trial with bigger devices. Hype is a controlled randomized trial comparing anti coagulation to catheter directed lyrics. PE tracked giant giant big deal funded controlled randomized trial just like hype. So we will be a part of that trial. Um Flash PE Rescue PE are also ongoing registries. There's two more that were actively a part of randomizing treatment to anti coagulation or now randomizing treatment types and all really important questions that will be able to answer maybe in a year or two. This is not important. Clot porn is something that I've started to hashtag and talk about nationally, which is the idea of showing how much clot we can take out of people. Industry loves this. There's no industry in the room right now. So I have no problem saying this. All of them have websites dedicated to clot porn. Please don't google this, do not google clot porn on your phones, but they all talk about the stuff they pull out and no matter which system does it, they all show you all these big, giant impressive goobers, but nobody should care about what we care about is that the patient actually gets better. So clinical follow up is critical. So if you're getting catheter directed therapy, we're swapping patients still in 2022. We're watching pressure's getting better. We're watching their biomarkers until they normalize. We're getting them 48 hour echoes and to is to figure out if the heart's improving and the clot burdens improving, it's critically important that if we want to say that we're fixing people to improve right heart strain before they go home, that we actually fix right heart strain before they go home. Otherwise we're just putting tubes in people and making clot porn. So with that I'll take my pager back from you and I'll take questions at the end. Thanks guys Published Created by Related Presenters David J. Dexter, II, M.D. Sentara Vascular Specialists View full profile
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