6 th Annual Scientific Sessions Georgia Vascular Society Reynolds Plantation, Lake Oconee 9/15/2018

Transcription

1 Current Outcomes of Management of Massive Pulmonary Embolism Achieved by a Multidisciplinary Pulmonary Embolism Response Team in a Quaternary Referral Center Presentation Sponsor: Charles B. Ross, M.D., F.A.C.S. Piedmont Heart and Vascular Institute Piedmont Atlanta Hospital Atlanta, Georgia 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. 6 th Annual Scientific Sessions Georgia Vascular Society Reynolds Plantation, Lake Oconee 9/5/08

2 Developing a PERT 4/3/08 Disclosures Charles B. Ross, M.D., F.A.C.S. Consultant EKOS/BTG Corp Board of Directors (06 0/09)

3 Pulmonary Embolism Scope of the Problem PE 50,000 to 50,000 hospitalizations per year 60,000 to 00,000 deaths/ year Third-leading cause of cardiovascular death % present as sudden death - incidence is likely underestimated - 4% incidence of CTEPH Sentinel event in any patient s life Courtesy of Fred Milla, M.D. PAH PERT August 3, 08 3

4 Large Thrombus Burden PE 08: Risk for PE-Related Death 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 PERT management Intermediate Risk - 5% H I G H 5% Low Risk 70% Standard VTE management 4

5 Essence of the PERT Approach to care for High-Risk PE bringing order to chaos 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 5

6 PAH PERT PAH PE Program 0: Vascular Surgery Pulmonary Critical Care Medicine CT Surgery ECMO Team PAH Multidisciplinary PERT Leader Dr. Charles Ross, MD ED Dr. Sean Sue, MD Pulm-CCM - GLA Critical Care MD and APP staff Interventional Card Drs. Klein, Kaul, and Kandzari Vasc/Endovasc Surg Drs. Ross, Ben-Arie, Unzeitig, and Chahwala CV ICU/ECMO Dr. Barrett CT Surgery Dr. Milla (champion) & staff Hematology Dr. Jonas & partners APPs GLA, CCU, Vascular Nursing 4 East ICU, CCU, & CVCU Level I Coordinator Grant Reynolds Decision Support Mike Lunney Cath lab/ir/or Staff 6

7 The PAH PERT s Approach. ED and P-CCM see first. 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 7

8 0 Quarterly PERT Activations July 04-August Q3 04 Q4 04 Q 05 Q 05 Q3 05 Q4 05 Q 06 Q 06 Q3 06 Q4 06 Q 07 Q 07 Q3 07 Q4 07 Q 08 Q 08 Q3 08 Submassive PE Massive PE 8

9 PAH PERT Experience with Massive PE Massive Pulmonary Embolism Definition Acute PE in the presence of hypotension SBP < than 90 mmhg for > 5 minutes SBP 40 mmhg less than baseline Vasopressor support required to maintain SBP > 90 mmhg - 90 day mortality > than 5% and as high as 80% 9

10 PAH PERT Experience with Massive PE Purpose: 3 minute response target Review the PAH PERT experience with massive PE Retrospective review of a prospective database Documented PE 7/04 7/08 Evaluate management strategies Outcomes 0

11 PAH PERT Experience with Massive PE Patient Population: Gender: 50% male 50% female Age: Mean: 57.7 Median: 59.5 Comorbidities: Comorbidity Percentage of Patients Previously healthy 3.85% BMI > 4.9 (normal) 88.46% BMI > 30 (obese) 69.3% Pre-existing cardiopulmonary disease 3.85% Active neoplastic disease 5.38% Recent surgery or trauma 46.5%

12 PAH PERT Experience with Massive PE Total Reviewed Population = 8 Patients Population analyzed = 6 Patients Excluded patients = Patients *Excluded patients presented either with CPR in progress or had palliative care initiated upon arrival at PAH

13 PAH PERT Experience with Massive PE Patient Presentation SYNCOPE CPR PRIOR TO INTERVENTION CPR AT ANY POINT PRESSOR SUPPORT 7 patients patients 3 patients 5 patients 7% 4% 50% 96% 3

14 Definitive Management Systemic thrombolysis UA-CDT (ECMO stand-by) Surgical Embolectomy PAH PERT Experience with Massive PE Number of patients Number survived Percent survival Overall length of stay (days) Length of stay of survivors (days) % % % VA-ECMO (only) 0 0.0% 5.00 N/A VA-ECMO + UA- CDT Data and Outcomes: % All intervention %

15 PAH PERT Experience with Massive PE Non-survivors 7 patients (6.9%) Anoxic Brain Injury patients (7.7%) Persistent right ventricular failure with multi-system organ failure 4 patients (5.4%) Refractory cardiogenic shock patient (3.8%) 5

16 PAH PERT Experience with Massive PE Survivorship by presentation and management Syncope CPR Prior to Intervention CPR at Any Point Pressor Support Systemic Thrombolysis 00% survived / patient 50% survived / patients 50% survived / patients 50% survived /4 patients UA-CDT 00% survived 3/3 patients 00% survived 3/3 patients 00% survived 4/4 patients 00% survived 8/8 patients Surgical Embolectomy 00% survived / patients N/A 0 patients 0% survived 0/ patient 7% survived 5/7 patients VA-ECMO 0% survived 0/ patient 0% survived 0/ patients 0% survived 0/ patients 0% survived 0/ patients VA-ECMO + UA-CDT 00% survived / patient 75% survived 3/4 patients 75% survived 3/4 patients 75% survived 3/4 patients Total 86% survived 6/7 patients 64% survived 7/ patients 6% survived 8/3 patients 7% survived 8/5 patients 6

17 Evolution of Approaches to Massive PE Survivorship Benchmarks Massive PE Overall Mortality ICOPER Registry Data Massachusetts General Hospital Piedmont Atlanta Hospital 58% Goldhaber SZ, Visani L, De Rosa M. The Lancet. 999; 353: % Kabrhel C, Rosovsky R, Channick R, et al. Chest. 06;50: % Present series 7

18 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% 8

19 Conclusion In conclusion, massive PE has accounted for 3 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 9

20 Interspecialty Collaboration - PERT VAM 6/0/08 PAH PERT PE Interventionalists Charles Ross, M.D. Eyal Ben Arie, M.D. Andrew Unzeitig, M.D. Veer Chahwala, M.D. David Kandzari, M.D. Drew Klein, M.D. Prashant Kaul, MD Grant Reynolds, BS, RN Coordinator 0

21 Quarterly PE Intervention by Physician Q3 04 Q4 04 Q 05 Q 05 Q3 05 Q4 05 Q 06 Q 06 Q3 06 Q4 06 Q 07 Q 07 Q3 07 Q4 07 Q 08 Q 08 Q3 08 Charles Ross Eyal Ben-Arie Andrew Unzeitig Drew Klein Prashant Kaul Veer Chahwala

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