A Pulmonary Embolism Response Team (PERT) Approach: Early Experience From the Cleveland Clinic

SESSION TITLE: Pulmonary Embolism: Assessment and Outcomes SESSION TYPE: Original Investigation Slide PRESENTED ON: Sunday, October 23, 2016 at 04:30 PM - 05:30 PM PURPOSE: Management of sub-massive and massive acute PE is challenging. The role of multidisciplinary teams for the care of these patients is emerging. Herein, we report our experience with a PERT comprising of members from Pulmonary/Critical Care, Vascular Medicine, Cardiology, Cardiothoracic surgery, Emergency Medicine and Interventional Radiology. METHODS: We conducted a retrospective chart review on all patients admitted to the medical ICU who required activation of the Pulmonary Embolism Response team (PERT) from January 2015- February 2016. We extracted data pertaining to clinical presentation, bleeding complications, and pre- and post-discharge imaging. Patients were classified as low risk, sub-massive or massive PE. Upon activation of the PERT, a virtual meeting was held between its members and after deliberation, patients received low-dose tPA, full dose tPA, catheter directed tPA, surgical embolectomy or anticoagulation alone. These patients were followed up after discharge in the vascular medicine clinic. Patients with incomplete follow up data were excluded from the analysis. RESULTS: 84 patients were evaluated by the team. Complete data were available in 71 patients. 8 (11.3%) patients were classified as low risk, 50(70.4%) sub-massive PE and 13(18.3%) massive PE. 52(73.2%) patients had a lower extremity DVT. 55(77.5%) had abnormal vital signs on admission to the ICU and 63(88.7%) patients had evidence of right ventricular (RV) strain on Echo or CT. 9(12.7%) patients were treated with catheter directed tPA , 3(4.2%) received full dose tPA, 11(15.5%) received low-dose tPA, 2(2.8%) underwent a surgical embolectomy and 1(1.4%) underwent suction thrombectomy(everyone received full dose anticoagulation with heparin). 29(40.8%) patients received an IVC filter. 16 patients had bleeding complications. 4 (44%) patients in the catheter directed tPA group had clinically significant bleeding. There were no bleeding complications among patients who received low-dose or full dose tPA. 12(25%) patients who received anticoagulation without tPA had documented bleeding. 5(7%) patients died while in the medical ICU. There were no deaths among patients who received any form of tPA. All 11 patients who were treated with low-dose tPA normalized their vitals and also did not show signs of RV strain on discharge and follow up Echo after three to six months compared to 2(22.2%) of the patients treated with catheter directed tPA who still had signs of RV strain. The mean reduction in RVSP on follow up was 29 ± 12 mmHg in the low-dose tPA group compared to 14 ± 15 mmHg in patients treated with catheter directed tPA and 17 ± 11 mmHg among patients who received anticoagulation only. CONCLUSIONS: A multidisciplinary approach to cases of sub-massive and massive PE can be implemented successfully. In our limited cohort, patients who received low-dose tPA had lower bleeding risk, higher resolution of RV strain and greater reduction in RVSP on follow up Echo compared to patients who received catheter directed tPA or anticoagulation alone. CLINICAL IMPLICATIONS: Patients presenting with sub-massive and massive PE should be evaluated via a multidisciplinary approach. In highly selected patients, low-dose tPA may be used in a safe and effective manner. DISCLOSURE: The following authors have nothing to disclose: Jamal Mahar, Divyajot Sadana, Nancy Nguyen, Seth Bauer, Ihab Haddadin, Mehdi Shishehbor, Nicholas Smedira, Phillip Erwin, Michael Militello, Michael Zhen-Yu Tong, Natalie Evans, John Bartholomew, Gustavo Heresi No Product/Research Disclosure Information