Multidisciplinary Pulmonary Embolism Response Team Research Articles

Assessing PERT integration: a European survey on pulmonary embolism response teams

Abstract Funding Acknowledgements None. Background In recent years, the establishment of multidisciplinary pulmonary embolism response teams (PERTs) has become more prevalent in response to the growing challenges in managing acute pulmonary embolism (PE). A survey was conducted to assess the availability and structure of PERTs in selected European PE reference centers. Methods A survey was circulated among leading European PE centers to obtain data on their current PE treatments, the existence and features of PERTs, their activation methods, and their structural organization. Additionally, data regarding PE treatment priority relative to acute coronary syndrome and the availability of outpatient PE follow-up programs was collected. Results Overall, 26 selected reference centers for PE from 13 European countries participated at this survey and in more than four fifth (80.8%) of the centers PERT is already implemented. Although 76.9% of the centers handle over 40 PE cases annually, less than half (42.8%) of their PE cases are discussed in a PERT meeting. Figure 1A illustrates the risk classifications for which PERTs are typically consulted. The most common method of activating PERTs is through phone calls (47.6%), followed by mobile apps (38.1%) and pagers (4.8%). In almost 60% PERT is leading from the Department of Cardiology followed by Pulmonology (18.2%), Critical Care Medicine (9.1%), General Internal Medicine (4.6%), Angiology (4.6%) and Radiology (4.6%) (Figure 1B and 1C). Regarding advanced treatment the majority of European expert centers for PE offers catheter-directed thrombolysis (78.3%) and catheter-based thrombectomy (78.3%) and the opportunity of surgical embolectomy (65.2%). Notably, over 46% of centers prioritize ST-elevation infarction over high-risk PE (Figure 1D). The follow-up of patients with PE is organized in 34.6% in a dedicated PE clinic, in 23.1%in the clinic of the physician leading PERT and in 7.7% no PE follow-up is available. Conclusion The findings confirm the widespread adoption of PERTs in European PE reference centers. However, there is a discernible trend of prioritizing myocardial infarction over PE with hemodynamic instability, even when mortality rates are comparable for high-risk PE cases. This emphasizes the pressing need for awareness campaigns to enlighten physicians about the significant mortality rates linked with unstable PE, aiming for enhanced management and intervention for this thrombotic disease.

Treatment of high- and intermediate-high-risk pulmonary embolism by the Pulmonary Embolism Response Team: Focus on catheter-directed therapies.

Multidisciplinary Pulmonary Embolism Response Teams (PERTs) were established to individualize the treatment of high-risk (HR) and intermediate-high-risk (IHR) pulmonary embolism (PE) patients, which pose a challenge in clinical practice. We retrospectively collected the data of all HR and IHR acute PE patients consulted by PERT CELZAT between September 2017 and October 2022. The patient population was divided into four different treatment methods: anticoagulation alone (AC), systemic thrombolysis (ST), surgical embolectomy (SE), and catheter-directed therapies (CDTx). Baseline clinical characteristics, risk stratification, PE severity parameters, and treatment outcomes were compared between the four groups. Of the 110 patients with HR and IHR PE, 67 (61%) patients were treated with AC only, 11 (10%) with ST, 15 (14%) underwent SE, and 17 (15%) were treated with CTDx. The most common treatment option in the HR group was reperfusion therapy, used in 20/24 (83%) cases, including ST in 7 (29%) patients, SE in 5 (21%) patients, and CTDx in 8 (33%) patients. In contrast, IHR patients were treated with AC alone in 63/86 (73%) cases. The in-hospital mortality rate was 9/24 (37.5%) in the HR group and 4/86 (4.7%) in the IHR group. The number of advanced procedures aimed at reperfusion was substantially higher in the HR group than in the IHR PE group. Despite the common use of advanced reperfusion techniques in the HR group, patient mortality remained high. There is a need further to optimize the treatment of patients with HR PE to improve outcomes.

Reduced mortality associated with pulmonary embolism response team consultation for intermediate and high-risk pulmonary embolism: a retrospective cohort study

BackgroundThe management of acute pulmonary embolism (PE) has become increasingly complex with the expansion of advanced therapeutic options, resulting in the development and widespread adoption of multidisciplinary Pulmonary Embolism Response Teams (PERTs). Much of the literature evaluating the impact of PERTs has been limited by pre- postimplementation study design, leading to confounding by changes in global practice patterns over time, and has yielded mixed results. To address this ambiguity, we conducted a retrospective cohort study to evaluate the impact of the distinct exposures of PERT availability and direct PERT consultation.MethodsAt a single tertiary center, we conducted propensity-matched analyses of hospitalized patients with intermediate or high-risk PE. To assess the impact of PERT availability, we evaluated the changes in 30-day mortality, hospital length of stay (HLOS), time to therapeutic anticoagulation (TAC), in-hospital bleeding complications, and use of advanced therapies between the two years preceding and following PERT implementation. To evaluate the impact of direct PERT consultation, we conducted the same analyses in the post-PERT era, comparing patients who did and did not receive PERT consultation.ResultsSix hundred eighty four patients were included, of which 315 were pre-PERT patients. Of the 367 postPERT patients, 201 received PERT consultation. For patients who received PERT consultation, we observed a significant reduction in 30-day mortality (5% vs 20%, OR 0.38, p = 0.0024), HLOS.(-5.4 days, p < 0.001), TAC (-0.25 h, p = 0.041), and in-hospital bleeding (OR 0.28, p = 0.011).These differences were not observed evaluating the impact of PERT presence in pre-vs postimplementation eras.ConclusionsWe observed a significant reduction in 30-day mortality, hospital LOS, TAC, and in-hospital bleeding complications for patients who received PERT consultation without an observed difference in these metrics when comparing the pre- vs post-implementation eras. This suggests the benefits stem from direct PERT involvement rather than the mere existence of PERT. Our data supports that PERT consultation may provide benefit to patients with acute intermediate or high-risk PE and can be achieved without a concomitant increase in advanced therapies.

A multidisciplinary pulmonary embolism response team (PERT): first experience from a single center in Germany.

Over the last few years, the concept of multidisciplinary pulmonary embolism response teams (PERTs) has emerged to encounter the increasing variety and complexity in managing acute pulmonary embolism (PE). To investigate PERT's composition and added clinical value in a university center in Germany. Over 4years (01/2019-11/2022), patients with confirmed PE were enrolled in a prospective single-center cohort study (PERT Mainz). We investigated the composition of PERT and compared, after propensity score matching, patients with acute PE before and after the initiation of PERT at our Medical University Centre. The primary outcome was in-hospital PE-related mortality. From 2019 to 2022, 88 patients with acute PE with a PERT decision were registered. Of those, 13 (14.8%) patients died during the in-hospital stay. Patients evaluated by a PERT had a median age of 68; 48.9% were females, and 21.7% suffered from malignancy. Right ventricular dysfunction was present in 76.1% of all patients. In total, 42.0% were classified as intermediate-high-risk PE and 11.4% as high-risk PE. First PERT contact mainly originated from emergency departments (33.3%) and intensive care units (30.0%), followed by chest pain units (21.3%) and regular wards (12.0%). The participation rate of medical specialties demonstrated that cardiologists (100%) or cardiac/vascular surgeons (98.6%) were included in almost all PERT consultations, followed by radiologists (95.9%) and anesthesiologists (87.8%). Compared to the PERT era, more patients in the pre-PERT era were classified as simplified pulmonary embolism severity index (sPESI) ≥ 1 (78.4% vs 71.6%) and as high-risk PE according to ESC 2019 guidelines (18.2% vs. 11.4%). In the pre-PERT era, low- and intermediate-low patients with PE received more frequently advanced reperfusion therapies such as systemic thrombolysis or surgical embolectomy compared to the PERT era (10.7% vs. 2.5%). Patients in the pre-PERT were found to have a considerably higher all-cause mortality and PE-related mortality rate (31.8% vs. 14.8%) compared to patients in the PERT era (22.7% vs. 13.6%). After propensity matching (1:1) by including parameters as age, sex, sPESI, and ESC risk classes, univariate regression analyses demonstrated that the PE management based on a PERT decision was associated with lower risk of all-cause mortality (OR, 0.37 [95%CI 0.18-0.77]; p = 0.009). For PE-related mortality, a tendency for reduction was observed (OR, 0.54 [95%CI 0.24-1.18]; p = 0.121). PERT implementation was associated with a lower risk of all-cause mortality rate in patients with acute PE. Large prospective studies are needed further to explore the impact of PERTs on clinical outcomes.

Abstract 14389: Mitigating Health Disparities by Improving Access to Advanced Multidisciplinary Care for Vulnerable Patients With Intermediate and High-Risk Pulmonary Embolism

Background: Vulnerable patients, including minorities and underserved populations whose care rely on public hospitals, have limited access to advanced pulmonary embolism (PE) treatment, particularly when catheter-based therapies (CBT) and escalation of care are needed. Our aim is to describe the multidisciplinary pulmonary embolism response team (PERT) program for the largest public health system in the country, as a strategy to mitigate healthcare disparities and improve access to care. Methods: We collected clinical, demographic and socioeconomic data from patients with intermediate-high and high-risk PE undergoing CBT at Bellevue Hospital, a PERT referral center and level 1 shock center for New York City’s Health and Hospitals’ network. Outcomes included in-hospital mortality and complications from CBT. Results: Sixty-one patients were included (42.6% women, age 57 ± 13.7 years) between October, 2022 to April 2023; 80.3% had intermediate-risk PE, 19.7%% had high-risk PE. The majority were black (57.4%), followed by Hispanic (13%). A total of 13% were uninsured, 9.8% were undocumented and 50.8% lived below the poverty level for New York City. The level of education was 8th grade or less in 4.9% of patients, high school in 29.5%, at least 2 years of college in 6.6%, &gt;4 years of college in 8.2%, master’s degree in 4.9% and unknown in 46%. Disease severity markers (CPES, PESI, BOVA, lactate, troponin and BNP) did not vary by ethnic group. There were no differences in mortality between white and non-white patients (figure); 3(4.9%) patients required rescue extracorporeal support and there were no procedural related complications. Conclusions: Our multidisciplinary PERT program demonstrates feasibility to provide care to underserved and vulnerable populations with excellent outcomes, serving as a strategy to help decrease healthcare disparities, particularly for advanced therapies for a challenging condition such as intermediate and high-risk PE.

Abstract 18534: Catheter-Directed Mechanical Thrombectomy: A PERTinent Paradigm Shift

Introduction: The emergence of catheter-directed mechanical thrombectomy (MT) heralded a paradigm shift in the management of pulmonary embolism (PE). There is a paucity of data on the degree to which the availability of this modality has impacted clinical-decision making by the multidisciplinary Pulmonary Embolism Response Team (PERT). We examine data from a single center experience at a large tertiary hospital to shed light. Research Question: How does the recent emergence of MT as a therapeutic strategy impact the approach of a PERT team? Aim: To examine the degree to which the integration of MT into the clinical decision-making algorithm for PE management has impacted the treatment course recommended by a PERT team. Methods: A retrospective analysis was performed to compare PERT recommendations in a contemporary cohort (10/2020-3/2023) to a historical cohort (1/2015-6/2016) prior to the availability of newer generation mechanical thrombectomy catheters in the same institution. Results: The contemporary cohort consisted of 306 patients, of which 50% were treated with advanced therapies including MT, catheter-directed lysis, systemic tPA, or ECMO. In the historical cohort, 28% of patients received advanced therapies. Of those treated with advanced therapies, 84% were MT and 1% were catheter-directed lysis in the contemporary cohort compared to 6% MT and 31% catheter-directed lysis in the historical PERT cohort. Conclusion: The integration of MT into the PERT decision-making process portends a new era in the management of PE. At our center, it significantly expanded the ambit of advanced therapies, such that a majority of patients now receive some form of advanced therapy, rather than anticoagulation alone. This is in stark contrast with the pre-MT era. These findings underscore the importance of a PERT team’s ability to adapt to evolving treatment modalities and highlights the need for continued multidisciplinary expertise in optimizing care for PE patients.

Multidisciplinary Pulmonary Embolism Response Team (PERT) a propensity score matched single centre experience from Germany

Abstract Funding Acknowledgements Type of funding sources: None. Background Over the last years, the concept of multidisciplinary pulmonary embolism response teams (PERTs) has emerged to encounter the increasing variety and complexity in the management of acute pulmonary embolism (PE). Purpose To investigate the composition and added clinical value of PERT in our city. Methods Over a 5-year period (01/2017-09/2022), patients with confirmed PE were enrolled in a prospective single-centre cohort study (PERT). We investigated the composition of PERT and compared, after propensity score matching, patients with acute PE prior and after the formation of PERT at our institution. The primary outcome was in-hospital PE-related mortality before and after the formation of PERT. Results During the period from 2017 to 2022, 88 patients with acute PE with a PERT decision were registered. Of those, 13 (14.8%) patients died during the in-hospital stay. Patients evaluated by a PERT had a mean age of 68 years; among these 48.9% were females, and 21.7% suffered from malignancy. Right ventricular dysfunction was present in 84.9% of the patients. In total, 42.0% were classified as intermediate-risk PE and 11.6% as high-risk PE. First PERT contact originated mostly by emergency departments (33.3 %) and intensive care unit (30.0%), followed by chest pain unit (21.3%) and regular ward (12.0%) (Figure 1a). The participation rate of specialties demonstrated that cardiologists (100%) or cardiac/vascular surgeons (98.6%) were included in almost all PERT activations followed by radiologist (95.9%) or anesthesiologist (87.8%). Further disciplines were present in few cases as summarized in Figure 1b. When comparing patients characteristics of the pre-PERT era with the PERT era, more patients were classified as sPESI ≥1 and as high-risk according to ESC 2019 guidelines in the pre-PERT era (78.4% and 18.2%) opposed to the PERT era (71.6 and 11.4%) (Figure 2). A considerable higher all-cause mortality (31.8% vs. 14.8%) and PE-related mortality rate (22.7% vs. 13.6%) was observed in patients in the pre-PERT era compared to the PERT era. After propensity matching (1:1) by including parameters as age, sex, sPESI and ESC risk classes, an univariate regression analyses demonstrated, that the PE management based on a PERT-decision was associated with lower risk of all-cause mortality (OR, 0.37 [95%CI 0.18-0.77]; p=0.009) and PE-related mortality (OR, 0.54 [95%CI 0.24-1.18]; p=0.121) compared to patients without a PERT-decision. Conclusion PERT implementation tended to reduce the mortality rate in patients with acute PE. Large prospective studies are needed to further explore the impact of PERTs on clinical outcomes.

Surgical Management and Mechanical Circulatory Support in High-Risk Pulmonary Embolisms: Historical Context, Current Status, and Future Directions: A Scientific Statement From the American Heart Association.

Acute pulmonary embolism is the third leading cause of cardiovascular death, with most pulmonary embolism-related mortality associated with acute right ventricular failure. Although there has recently been increased clinical attention to acute pulmonary embolism with the adoption of multidisciplinary pulmonary embolism response teams, mortality of patients with pulmonary embolism who present with hemodynamic compromise remains high when current guideline-directed therapy is followed. Because historical data and practice patterns affect current consensus treatment recommendations, surgical embolectomy has largely been relegated to patients who have contraindications to other treatments or when other treatment modalities fail. Despite a selection bias toward patients with greater illness, a growing body of literature describes the safety and efficacy of the surgical management of acute pulmonary embolism, especially in the hemodynamically compromised population. The purpose of this document is to describe modern techniques, strategies, and outcomes of surgical embolectomy and venoarterial extracorporeal membrane oxygenation and to suggest strategies to better understand the role of surgery in the management of pulmonary embolisms.

Risk stratification and risk-adapted management of acute pulmonary embolism.

Pulmonary embolism is one of the leading causes of cardiovascular death in Europe. Rapid diagnosis and treatment initiation are essential, especially in hemodynamically unstable patients. For normotensive patients, the diagnostic workflow is based on the clinical probability of pulmonary embolism. Due to numerous differential diagnoses and ahighly variable clinical presentation, diagnosis of acute pulmonary embolism still remains aclinical challenge. Computed tomography angiography is the common gold standard to confirm pulmonary embolism and bedside echocardiography adds amajor impact in clinical decision making. The European Society of Cardiology guidelines serve as aframework for astandardized diagnostic approach and risk prediction. Based on vital signs, clinical scores, biomarkers and imaging results, four risk categories can be defined and treatment is accordingly. To optimize the individual management of critical patients, multidisciplinary pulmonary embolism response teams are increasingly designated in specialized centers. This article provides an overview of the current risk-adapted management of patients with acute pulmonary embolism.

Standardization of Pulmonary Embolism Evaluation and Management Through Implementation of a Pulmonary Embolism Response Team: A Single-Center Experience at Brooke Army Medical Center.

Pulmonary embolism (PE) is associated with significant rates of morbidity and mortality. Management of PE is complex, and adverse patient events are not uncommon. Brooke Army Medical Center (BAMC) is among several select institutions that have implemented multidisciplinary pulmonary embolism response teams (PERTs) to improve PE outcomes. PERT structure varies among institutions and often involves specialty expertise from a variety of departments within the hospital. PE response teams aim to improve the diagnosis and treatment for patients with acute PE. Here, we report our initial experience with this intervention. We developed a multidisciplinary PERT and implemented a standardized algorithm to guide the evaluation, management, and disposition of patients with acute PE. Patients with PE were identified in the pre-PERT period (2015-2017) and the post-PERT period (2020-2021). A retrospective analysis of clinical characteristics, management strategies, and outcomes was performed for both cohorts. A total of 68 patients with acute PE were analyzed, 38 patients before PERT adoption, and 30 patients post-PERT. Baseline characteristics between the two cohorts were similar. A statistically significant increase in the evaluation for right ventricle dysfunction was noted in the post-PERT cohort, with 80% of patients having pro-brain natriuretic peptide labs obtained compared to 47% in the pre-PERT cohort (P = .005). Furthermore, 97% of patients in the post-PERT cohort had a transthoracic echocardiogram compared to 55% in the pre-PERT cohort (P = .0001). Six patients in the pre-PERT cohort underwent catheter-directed thrombolysis, compared to zero in the post-PERT cohort (P = .006). There were no differences in other treatment modalities. There was no statistically significant difference in length of stay between the two cohorts. To our knowledge, this is the first report describing the successful implementation of a PERT at a military treatment facility to guide the evaluation, management, and treatment of PE. The implementation of the PERT improved the appropriate diagnostic evaluation for patients with intermediate-risk PE and reduced the use of non-guideline-based catheter-directed thrombolysis. This initiative serves as an example of what could be applied across other military treatment facilities within the Defense Health Agency.

Pulmonary embolism response team implementation and its clinical value across countries: a scoping review and meta-analysis

Abstract Background Over the last years, the concept of multidisciplinary pulmonary embolism response teams (PERTs) has been developed to encounter the increasing variety and complexity in the management of acute pulmonary embolism (PE), but data on the use and the benefit of PERT are sparse. Purpose We aimed to systematically investigate the composition of PERT and its clinical value in clinical routine across different countries. Methods We searched PubMed, CENTRAL and Web of Science until January 2022 for full-text, prospective and retrospective observational studies, which included patients with acute PE who were evaluated by a PERT. Eligible articles were designed to either describe the structure and function of PERTs and/or to investigate outcomes related to the implementation of PERT. We performed a random-effects meta-analysis of controlled studies (PERT vs. pre-PERT era) to investigate the impact of PERTs on clinical outcomes and use of advanced therapies. Results We included 22 original studies and four surveys. Overall, 31.5% of patients with PE were evaluated by PERT referred mostly by emergency departments (59.4%). In total, PERT involved a median of 6 (range 2–10) specialties for guiding further diagnostic and treatment modalities. Patients evaluated by a PERT had a mean age of 60 years; of them, 48.7% were females, and 23.5% suffered from malignancy. Right ventricular dysfunction was present in 55% of the patients. In total, 74.5% were classified as intermediate-risk PE and 16% as high-risk PE. In eleven single-arm studies, 1,532 patients with intermediate- and high-risk PE were evaluated by PERT with a mortality rate of 10% and a bleeding rate of 9%. The mean length of stay was 7.3 days and the use of advanced therapy was reported in 30% of all cases. From these, catheter-directed treatment (CDT) was performed in 22% and inferior vena cava filter was inserted in 15%, while systemic thrombolysis was administered in only 6%, surgical thrombectomy in 2% and ECMO in 3% of all cases. When comparing PERT and pre-PERT era no difference in mortality (risk ratio [RR] 0.89, 95% confidence interval [CI] 0.67–1.19, I2=63%) was observed based on nine controlled studies, while mortality tended to be lower when including only intermediate and high-risk patients in the analysis (RR 0.71, 95% CI 045–1.12) (Figure 1). The use of advanced therapies was more common (RR 2.67, 95% CI 1.29–5.50) and the in-hospital stay as well as the duration of treatment in intensive care unit was shorter (mean difference −1.6 days and −1.8 days, respectively) in the PERT era. Conclusion PERT implementation tended to reduce the mortality rate in patients with intermediate- and high-risk PE and resulted in a shorter in-hospital stay. Large prospective studies are needed to further explore the impact of PERTs on clinical outcomes. Funding Acknowledgement Type of funding sources: None.

Trends in management and outcomes of pulmonary embolism with a multidisciplinary response team

Abstract Background Multidisciplinary pulmonary embolism (PE) response teams have garnered widespread adoption given the complexities of managing acute PE and provide a platform for assessment of trends in therapy and outcomes. We aimed to describe temporal trends in PE management and outcomes following the deployment of such a team. Methods All consecutive patients managed by our multidisciplinary PE response team activated by the Emergency Department were included over a 5-year calendar period. We examined temporal trends in management and rates of a composite primary endpoint (all-cause-death, major bleeding, recurrent venous thromboembolism, and readmission) at 30 days and 6 months. Results We assessed 425 patients between 2015 and 2019. We observed an increase in PE acuity and use of systemic thrombolysis. The primary endpoint at 30 days decreased from 16.3% in 2015 to 7.1% in 2019 (adjusted rate ratio per period, 0.63; 95% CI, 0.47–0.84), driven by a decrease in the adjusted rate of major bleeding. Among 406 patients with complete follow-up, the adjusted rate ratio per year for the primary outcome at 6 months was 0.37 (95% CI, 0.19–0.71), driven by a decrease in all-cause mortality. Conclusions We observed evidence of temporal changes in clinical presentation therapeutic strategies, and outcomes for acute PE, in parallel to, but not necessarily because of, the implementation of a multidisciplinary response team. Over time, major bleeding, mortality and readmission rates decreased, despite an increase in PE risk category. Funding Acknowledgement Type of funding sources: None.

CLOT IN TRANSIT: THE ROLE OF POINT-OF-CARE ULTRASOUND IN EARLY DIAGNOSIS AND IMPROVED OUTCOMES

CLOT IN TRANSIT: THE ROLE OF POINT-OF-CARE ULTRASOUND IN EARLY DIAGNOSIS AND IMPROVED OUTCOMES

Trends in management and outcomes of pulmonary embolism with a multidisciplinary response team.

Multidisciplinary pulmonary embolism (PE) response teams have garnered widespread adoption given the complexities of managing acute PE and provide a platform for assessment of trends in therapy and outcomes. We describe temporal trends in PE management and outcomes following the deployment of such a team. All consecutive patients managed by our multidisciplinary PE response team activated by the Emergency Department were included over a 5-year calendar period. We examined temporal trends in management and rates of a composite primary endpoint (all-cause-death, major bleeding, recurrent venous thromboembolism, and readmission) at 30days and 6months. We assessed 425 patients between 2015 and 2019. We observed an increase in PE acuity and use of systemic thrombolysis. The primary endpoint at 30days decreased from 16.3% in 2015 to 7.1% in 2019 (adjusted rate ratio per period, 0.63; 95%CI, 0.47-0.84), driven by a decrease in the adjusted rate of major bleeding. Among 406 patients with complete follow-up, the adjusted rate ratio per year for the primary outcome at 6months was 0.37 (95%CI, 0.19-0.71), driven by a decrease in all-cause mortality. We observed evidence of temporal changes in clinical presentation, therapeutic strategies, and outcomes for acute PE, in parallel to, but not necessarily because of, the implementation of a multidisciplinary response team. Over time, major bleeding, mortality and readmission rates decreased, despite an increase in PE risk category.

Pulmonary embolism response team (PERT) implementation and its clinical value across countries: a scoping review and meta-analysis

BackgroundOver the last years, multidisciplinary pulmonary embolism response teams (PERTs) have emerged to encounter the increasing variety and complexity in the management of acute pulmonary embolism (PE). We aimed to systematically investigate the composition and added clinical value of PERTs.MethodsWe searched PubMed, CENTRAL and Web of Science until January 2022 for articles designed to describe the structure and function of PERTs. We performed a random-effects meta-analysis of controlled studies (PERT vs. pre-PERT era) to investigate the impact of PERTs on clinical outcomes and advanced therapies use.ResultsWe included 22 original studies and four surveys. Overall, 31.5% of patients with PE were evaluated by PERT referred mostly by emergency departments (59.4%). In 11 single-arm studies (1532 intermediate-risk and high-risk patients evaluated by PERT) mortality rate was 10%, bleeding rate 9% and length of stay 7.3 days [95% confidence interval (CI) 5.7–8.9]. In nine controlled studies there was no difference in mortality [risk ratio (RR) 0.89, 95% CI 0.67–1.19] by comparing pre-PERT with PERT era. When analysing patients with intermediate or high-risk class only, the effect estimate for mortality tended to be lower for patients treated in the PERT era compared to those treated in the pre-PERT era (RR 0.71, 95% CI 0.45–1.12). The use of advanced therapies was higher (RR 2.67, 95% CI 1.29–5.50) and the in-hospital stay shorter (mean difference − 1.6 days) in PERT era compared to pre-PERT era.ConclusionsPERT implementation led to greater use of advanced therapies and shorter in-hospital stay. Our meta-analysis did not show a survival benefit in patients with PE since PERT implementation. Large prospective studies are needed to further explore the impact of PERTs on clinical outcomes.RegistrationOpen Science Framework 10.17605/OSF.IO/SBFK9.Graphical abstract

Characteristics and Outcomes of Patients Consulted by a Multidisciplinary Pulmonary Embolism Response Team: 5-Year Experience.

(1) Background: Pulmonary embolism (PE) is the third most frequent acute cardiovascular condition worldwide. PE response teams (PERTs) have been created to facilitate treatment implementation in PE patients. Here, we report on the 5-year experience of PERT operating in Warsaw, Poland, with regard to the characteristics and outcomes of the consulted patients. (2) Methods: Patients diagnosed with PE between September 2017 and December 2021 were included in the study. Clinical and treatment data were obtained from medical records. Patient outcomes were assessed in-hospital, at a 1- and 12-month follow-up. (3) Results: There were 235 PERT activations. The risk of early mortality was low in 51 patients (21.8%), intermediate–low in 83 (35.3%), intermediate–high in 80 (34.0%) and high in 21 (8.9%) patients. Anticoagulation alone was the most frequently administered treatment in all patient subgroups (altogether 84.7%). Systemic thrombolysis (47.6%) and interventional therapy (52%) were the prevailing treatment options in high-risk patients. The in-hospital mortality was 6.4%. The adverse events during 1-year follow-up included five deaths, two recurrent VTE and two minor bleeding events. (4) Conclusions: Our initial 5-year experience showed that the activity of the local PERT facilitated patient-tailored decision making and the access to advanced therapies, with subsequent low overall mortality and treatment complication rates, confirming the benefits of PERT implementation.

Effect of a Multidisciplinary Pulmonary Embolism Response Team on Patient Mortality

Multidisciplinary Pulmonary Embolism Response Teams (PERTs) may improve the care of patients with a high risk of pulmonary embolism (PE). The impact of a PERT on long-term mortality has never been evaluated. An observational analysis was conducted of 137 patients before PERT implementation (between 2014 and 2015) and 231 patients after PERT implementation (between 2016 and 2019), presenting to the emergency department of an academic medical center with submassive and massive PE. The primary outcome was 6-month mortality, evaluated by univariate and multivariate analyses. PERT was associated with a sustained reduction in mortality through 6months (6-month mortality rates of 14% post-PERT vs 24% pre-PERT, unadjusted hazard ratio of 0.57, Relative Risk Reduction of 43%, p=0.025). There was a reduced length of stay following PERT implementation (9.1 vs 6.5days, p=0.007). Time from triage to a diagnosis of PE was independently predictive of mortality, and the risk of mortality was reduced by 5% for each hour earlier that the diagnosis was made. In conclusion, this study is the first to demonstrate an association between PERT implementation and a sustained reduction in 6-month mortality for patients with high-risk PE.

CATASTROPHIC PULMONARY EMBOLISM SUCCESSFULLY TREATED WITH EXTRACORPOREAL MEMBRANE OXYGENATION

TOPIC: Critical Care TYPE: Medical Student/Resident Case Reports INTRODUCTION: Veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) is increasingly recognized as a modality for cardiopulmonary support in high-risk pulmonary embolism (PE). We report a successful application of VA ECMO to support a patient following cardiac arrest secondary to massive saddle PE. CASE PRESENTATION: A 35 year old woman was admitted with new cranial nerve palsies, concerning for neurosarcoidosis versus lymphoma. On hospital day (HD) 11 she became dyspneic and desaturated to 88% on room air; other vitals remained stable. CT chest revealed bilateral pulmonary artery occlusion with right heart strain. NT-proBNP was 3086 pg/mL (ref <125). Multidisciplinary Pulmonary Embolism Response Team (PERT) stratified her as "intermediate-high risk" PE, and recommended therapeutic heparin infusion, with resultant clinical improvement. On HD16 she developed acute chest pain with new tachycardia (HR 130), hypotension (BP 87/65) and increased oxygen requirements. S1Q3T3 pattern was noted on EKG. PE Severity Index (PESI) was 125 (Class IV), and PERT elected for urgent catheter-directed thrombectomy. Prior to procedure she suffered a cardiac arrest, and received ACLS plus systemic thrombolytics, with return of spontaneous circulation after 20 minutes. Post-arrest suction thrombectomy removed large clot burden, but with persistent hypotension despite inhaled nitric oxide, vasopressor and inotropic support and severe right ventricle (RV) systolic dysfunction on echocardiogram, she was peripherally cannulated for VA-ECMO. Her ECMO course was complicated by renal failure requiring renal replacement therapy and hemoperitoneum requiring blood transfusion. Vasopressors were weaned off on ECMO day 4, and she was decannulated on ECMO day 6. She was discharged on HD42, neurologically intact and with recovered cardiac and renal function. DISCUSSION: High-risk PE, defined by acute PE with hemodynamic instability, shock, or cardiac arrest, is associated with high mortality. VA ECMO allows for maintenance of organ perfusion and oxygenation by mechanically bypassing and decompressing the failing RV and pulmonary circulation, offering hemodynamic and respiratory support to allow for reperfusion strategies or spontaneous thrombolysis on heparin. ECMO is increasingly available, with mobile teams allowing for rapid deployment. The literature on ECMO as a rescue therapy for catastrophic PE is limited to small case series, and recent meta analyses were unable to draw definitive conclusions (1, 2). 2019 European guidelines suggest that mechanical cardiopulmonary support may be helpful for high-risk PE with circulatory collapse (3). CONCLUSIONS: This case adds to reports of successful use of VA-ECMO for high-risk PE. Early ECMO consultation and timely appropriate use may prevent sudden cardiac death. Further research is needed to determine what role ECMO may play as an early intervention rather than a salvage procedure. REFERENCE #1: Pozzi, Matteo, et al. "Efficacy and safety of extracorporeal membrane oxygenation for high-risk pulmonary embolism: A systematic review and meta-analysis." Vascular Medicine 25.5 (2020): 460-467. REFERENCE #2: Baldetti, Luca, et al. "Use of extracorporeal membrane oxygenation in high-risk acute pulmonary embolism." Artificial Organs (2020). REFERENCE #3: Konstantinides, Stavros V., et al. "2019 ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS) The Task Force for the diagnosis and management of acute pulmonary embolism of the European Society of Cardiology (ESC)." European heart journal 41.4 (2020): 543-603. DISCLOSURES: no disclosure on file for Stephanie Nonas; No relevant relationships by Jonathan Taylor, source=Web Response

MULTIDISCIPLINARY APPROACH USING CATHETER DIRECTED MECHANICAL THROMBECTOMY IN TREATMENT OF A PULMONARY EMBOLISM WITH CLOT IN TRANSIT

TOPIC: Pulmonary Vascular Disease TYPE: Fellow Case Reports INTRODUCTION: Clot in transit (CIT) is a term associated with pulmonary embolism (PE) used to describe thrombus found in the right atrium or ventricle on echocardiography. We present a case of CIT treated in a multidisciplinary approach with catheter-directed mechanical thrombectomy. CASE PRESENTATION: A 60 year old male with a history of unprovoked PE off anticoagulation presented with dyspnea and syncope. At presentation, he was tachycardic to 130 but normotensive and not hypoxemic. Troponin-I was elevated at 0.06 ng/mL and B type-NP at 96 pg/mL. SARS-CoV-2 PCR was negative. CT angiography revealed extensive acute bilateral PE with increased RV/LV ratio of 1.9. A stat transthoracic echocardiography (TTE) found a dilated right ventricle with severely reduced systolic function, positive McConnell sign, a tricuspid annular plane systolic excursion (TAPSE) < 1cm, and a serpiginous mobile echodensity in the right atrium consistent with a CIT. A stat ultrasound of the legs also revealed extensive deep venous thrombosis in the proximal left femoral vein extending to the popliteal vein. After a multidisciplinary PE response team discussion, the patient was taken emergently to the catheterization lab. Prior to transport, VA ECMO safety lines were preemptively placed to facilitate ECMO initiation in case of decompensation. With the ECMO circuit primed and the ECMO team, cardiac anesthesiologist, and cardiothoracic surgery on standby, the patient underwent percutaneous mechanical thrombectomy utilizing the Inari Flowtriever® system. With adjunctive TTE guidance, the right atrial clot was first extracted in its entirety with no hemodynamic deterioration. This was followed by aspiration of clot from the right and left pulmonary arteries. Pulmonary artery pressures and cardiac index improved, and the procedure ended with placement of an IVC filter. The patient was transferred to the ICU and was started on enoxaparin at 1mg/kg twice a day. He was discharged on day 4 with rivaroxaban. DISCUSSION: CIT is a rare phenomenon with a prevalence rate of around 4% and is considered a medical emergency given its high mortality rate of 25-40%. While treatment guidelines are limited, anticoagulation alone has shown to be insufficient to treat CIT effectively. While there is data supporting the use of catheter directed therapies for PE, data on its use for CIT is scarce but growing. Furthermore, the preparation of advanced support prior in conjunction with the use of catheter directed therapy may be beneficial in case of life-threatening decompensation. CONCLUSIONS: Catheter-directed mechanical thrombectomy may be effective and safe as shown in this case, but requires a team capable of advanced therapies like ECMO and urgent surgical intervention if needed. REFERENCE #1: Otoupalova E, Dalal B, Renard B. Right heart thrombus in transit: a series of two cases. Crit Ultrasound J. 2017;9(1):14. doi:10.1186/s13089-017-0069-9. REFERENCE #2: Garvey S, Dudzinski DM, Giordano N, Torrey J, Zheng H, Kabrhel C. Pulmonary embolism with clot in transit: An analysis of risk factors and outcomes. Thromb Res. 2020 Mar;187:139-147. doi: 10.1016/j.thromres.2020.01.006. Epub 2020 Jan 10. PMID: 31991381. REFERENCE #3: Dhulipala V R, Fayoda B O, Kyaw H, et al. (August 04, 2020) Thrombus in Transit: Extract or Dissolve?. Cureus 12(8): e9550. doi:10.7759/cureus.9550. DISCLOSURES: No relevant relationships by Mara Caroline, source=Web Response No relevant relationships by Eliot Friedman, source=Web Response No relevant relationships by Eric Gnall, source=Web Responseresearch relationship with Inari Please note: April,2021 to presen Added 04/29/2021 by Lee Greenspon, source=Web Response, value=Grant/Research Support No relevant relationships by Patrick Ho, source=Web Response

Catheter-directed therapy in pulmonary embolism.

Acute pulmonary embolism (PE) is alife-threatening condition with high mortality rates and potential long-term sequelae. Systemic thrombolysis has been virtually the only therapeutic option available for patients with hemodynamic instability over decades. Recently, interventional therapy of PE has gained increasing interest. Multiple devices were developed; these include devices for local thrombolysis, thrombus fragmentation, thrombus aspiration, and combined approaches. However, the available evidence is limited to mostly small, nonrandomized studies. In these studies, safety and efficacy data from patients with intermediate or high-risk PE are promising. However, due to the lack of adequately powered randomized trials, interventional treatment of intermediate or high-risk PE cannot be recommended as standard-of-care. The decision on whether and how to perform acatheter-based intervention should therefore be left to the discretion of the local team, depending on the patients' clinical status, bleeding risk, local expertise, and available devices. The implementation of local multidisciplinary PE response teams is recommended by international guidelines to provide the best possible treatment.