A New Paradigm in the Management of Massive and Submassive Pulmonary Embolism
December 1, 2016 5 minutes read
By Elaine Chen, MD
Assistant Professor, Department of Internal Medicine, Division of Pulmonary and Critical Care Medicine, Section of Palliative Medicine, Rush University Medical Center, Chicago
Dr. Chen reports no financial relationships relevant to this field of study.
SYNOPSIS: A multidisciplinary pulmonary embolism (PE) response team is a sustainable option to improve care for severe PE.
SOURCE: Kabrhel C, Rosovsky R, Channick R, et al. A multidisciplinary pulmonary embolism response team: Initial 30-month experience with a novel approach to delivery of care to patients with submassive and massive pulmonary embolism. Chest 2016;150:384-393.
Pulmonary embolism (PE) remains a common condition with high morbidity and mortality. Most cases are treated with systemic anticoagulation alone, but many other treatment options can be considered for severe cases. Real-time multispecialty discussion is required to integrate these treatments into clinical care.
To meet this need, a rapid response team was developed specifically for pulmonary embolism management, called the Pulmonary Embolism Response Team (PERT). The team included specialists in cardiology, cardiac surgery, echocardiography, emergency medicine, hematology, pulmonary/critical care, radiology, and vascular medicine. Upon activation, the team reviewed clinical data and conferred online in real time. After reaching a consensus, the team relayed the decision to the referring provider and mobilized recommended resources for interventions.
This report describes 30 months of data following initiation of the PERT. Confirmed PEs were characterized as massive (sustained hypotension or pulselessness), submassive (right ventricular dysfunction or myocardial necrosis without hypotension), or low risk (not meeting criteria for massive or submassive). Treatments recorded included anticoagulation, systemic IV thrombolysis, catheter-directed thrombolysis, suction thrombectomy, surgical thromboembolectomy, extracorporeal membrane oxygenation (ECMO), or inferior vena cava (IVC) filter placement that were delivered within three days of activation. In 30 months of measurement, the PERT was activated 394 times, increasing by 16% in each six-month measurement period. Most activations originated from the ED (58%), with the next most frequent from an ICU (20%). Three hundred fourteen (80%) patients had PE confirmed within three days of PERT activation. One hundred forty-three (46% of 314) were characterized as submassive, and 80 (25%) were characterized as massive. The majority of patients (69%) were treated with anticoagulation alone. Catheter-directed thrombolysis was utilized in 28 patients (9%), systemic IV thrombolysis in 14 (5%), surgical thrombectomy in eight (3%), and suction thrombectomy in one (0.3%).
Of the 80 patients with massive PE, 52 did not have a contraindication to thrombolysis, but 32 (62%) did not receive systemic, catheter-directed, or surgical thrombus removal. Bleeding complications occurred in 25 (8%) patients by day seven, and 11 (6%) patients between days eight and 30. More bleeding occurred in the IV thrombolysis group, but bleeding complications in the catheter-directed thrombolysis group were similar to those who received anticoagulation alone. Overall 30-day mortality was 12% (31/265) for those with confirmed PE, with higher mortality for those with massive PE compared with either submassive (P < 0.001) or low risk (P = 0.04). Those without confirmation of PE had the highest 30-day mortality of 49%.
This report represents the first longitudinal assessment of a new PE management paradigm. Adoption was immediate and sustained, and other national centers also have developed similar programs. Acknowledging differences between clinical data and registry data, the authors made a few comparisons. In the EMPEROR registry, 2% of PEs overall and 9% of PEs with hypotension were treated with thrombolysis, and in the ICOPER registry, 13% of PEs were treated with thrombolysis. At the current institution, prior to PERT initiation, 3% of PEs were treated with thrombolysis or thromboembolectomy. During the study period, 14% of patients overall and 23% of patients with massive PE were treated with some form of thrombolysis or thromboembolectomy, representing an increase in use of advanced therapies as a result of this formal process.
Establishing a PERT is an organizational process, requiring significant clinician effort and dedication as well as a high level of clinical service with 24-hour availability of rapid response teams, catheterization lab, and operating room services. The authors proposed that the PERT paradigm may come to represent a new standard of care for patients with PE.
COMMENTARY
While systemic anticoagulation alone is an appropriate treatment for low-risk PE, deciding on the most appropriate therapy for massive or submassive PE remains unclear. With availability and evolution of advanced interventions with possibly as much clinical benefit but significantly lower risk compared with systemic thrombolysis, the decision is becoming more challenging. Novel catheter-directed therapies continue to be tested and refined, and there remains no gold standard of therapy. Institutional experience with these therapies also can have a significant effect on outcomes.1,2
This process has been widely copied, though probably in varying forms, at both large academic centers as described in this report, as well as in community hospitals.3 In our institution, a similar program was established several years ago, because of recurrent retrospective discussions regarding the challenges to managing massive and submassive PE. Referring providers often had uncertainties about which consultant(s) to call, which therapies to request, managing multiple recommendations from different consultants, and coordinating next steps. With the initiation of our multidisciplinary team, the process of calling a consulting team has been standardized, resulting in a streamlined process for the referring provider.
Many of the benefits of a PERT are intangible and difficult to measure. Optimal treatment is difficult to define, as so many therapies are simultaneously evaluated in clinical practice, with new techniques constantly evolving. Myriad clinical variables dictate which therapies can be offered to each patient.
The gold standard for diagnosis of PE has evolved recently from pulmonary angiogram to CT PE. Will the standard for treatment of massive and submassive PE similarly evolve? As yet, we have no standard for optimal treatment for acute submassive PE, so multidisciplinary, expert consensus, clinical decision making is perhaps the best substitute for now.
REFERENCES
- Kuo WT, Banerjee A, Kim PS, et al. Pulmonary embolism response to fragmentation, embolectomy, and catheter thrombolysis (PERFECT): Initial results from a prospective multicenter registry. Chest 2015;148:667-673.
- Piazza G, Hohlfelder B, Jaff MR, et al. A prospective, single-arm, multicenter trial of ultrasound-facilitated, catheter-directed, low-dose fibrinolysis for acute massive and submassive pulmonary embolism: The SEATTLE II Study. J Am Coll Cardiol Intv 2015;6:1382-1392.
- Wisa DM, Zapata DI, Walczyszyn M, et al. Developing a pulmonary embolism response team (PERT) for the treatment of submassive pulmonary embolism. Am J Respir Crit Care Med 193;2016:A7368.
A multidisciplinary pulmonary embolism (PE) response team is a sustainable option to improve care for severe PE.
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