A pulmonary embolism response team's initial 20 month experience treating 87 patients with submassive and massive pulmonary embolism

Global hotspot and trend of extracorporeal membrane oxygenation for pulmonary embolism

Background

Research on extracorporeal membrane oxygenation (ECMO)-assisted support for pulmonary embolism (PE) has been increasing, yet no systematic bibliometric analysis has been conducted. This study evaluates global research trends in this field by analyzing countries, institutions, authors, journals, references, and keywords.

Methods

Relevant articles and reviews published up to August 15, 2023, were retrieved from the Web of Science Core Collection (WOSCC). VOSviewer and CiteSpace software were used for bibliometric analysis of collected data.

Results

Publications on ECMO-assisted support for PE surged from 2015 to 2023, comprising 82.7% (306/370) of total studies. The United States, Germany, and China contributed 62.97% (233/370) of the research. Perfusion-UK had the most publications, while Journal of the American College of Cardiology was the most cited journal. The University of Maryland, Massachusetts General Hospital, and Harvard Medical School were the leading institutions. Chetan Pasrija published the highest number of papers, while Konstantinidis SV was the most co-cited author. Research hot spots include: (1) ECMO management and survival rates, (2) combined treatments with thrombolysis or surgical thrombectomy, (3) anticoagulation and clot formation, and (4) ECMO support in COVID-19.

Conclusion

This study aims to increase awareness of research hot spots on ECMO-assisted support for PE by determining the collaboration and impact of authors, countries, institutions, and journals. In addition, it comprehensively reviews research trends on ECMO regarding PE. It also provides a reference for potential collaborators, institutions, and future research prospects.

Bringing PERT to Pediatrics: Initial Experience and Outcomes of a Pediatric Multidisciplinary Pulmonary Embolism Response Team (PERT)

BACKGROUND

Multidisciplinary pulmonary embolism response teams (PERTs) streamline care of adults with life-threatening pulmonary embolism (PE). Given rarity of pediatric PE, developing a clinical, educational, and research PERT paradigm is a novel and underused concept in pediatrics.

RESEARCH QUESTION

Is a PERT feasible in pediatrics, and does it improve PE care?

STUDY DESIGN AND METHODS

A strategy-to-execution proposal to launch a pediatric PERT was developed for institutional buy-in. Key stakeholders collectively implemented the PERT. Data were collected for the 2-year pre-PERT and post-PERT eras, and outcomes were compared.

RESULTS

PERT implementation took 12 months. Our PERT, led by hematology, is composed of pediatric experts in emergency medicine, critical care, interventional cardiology, anesthesiology, and interventional radiology. Data on 30 patients pre-PERT and 31 patients post-PERT were analyzed. Pre-PERT, 10% (3 of 30), 13% (4 of 30), 20% (6 of 30), and 57% (17 of 30), and post-PERT, 3% (1 of 31), 10% (3 of 31), 16% (5 of 31), and 71% (22 of 31) were categorized as high-risk, intermediate-low-risk, intermediate-high-risk, and low-risk PE, respectively. Post-PERT, there were 13 unique PERT activations. PERT was activated on all eligible patients with PE and, additionally, on four low-risk PEs. Time to echocardiogram was shorter post-PERT (4.7 vs 2 hours; P = .0147). Anticoagulation was ordered (90 vs 54 min; P = .003) and given sooner (154 vs 113 min; P = .049) post-PERT. There were no differences in time to reperfusion therapies (12 hours pre-PERT vs 8.7 hours post-PERT, P = .10). Five of six (83.3%) eligible (intermediate-high and high-risk) patients received reperfusion therapies in the post-PERT era compared to three of eight (37.5%) eligible patients in the pre-PERT era (P = .0001). There were no differences in major bleeding, mortality, or length of stay in either era.

INTERPRETATION

The pediatric PERT paradigm was successfully created and adopted locally. Our PERT enhanced access to experts, facilitated timely advanced therapies, and held value for low-risk PE. The University of Texas Southwestern Medical Center and Children's Medical Center pediatric PERT may serve as a best practice model for streamlining care for pediatric PE.

Multidisciplinary Care Teams in Acute Cardiovascular Care: A Review of Composition, Logistics, Outcomes, Training, and Future Directions

As cardiovascular care continues to advance and with an aging population with higher comorbidities, the epidemiology of the cardiac intensive care unit has undergone a paradigm shift. There has been increasing emphasis on the development of multidisciplinary teams (MDTs) for providing holistic care to complex critically ill patients, analogous to heart teams for chronic cardiovascular care. Outside of cardiovascular medicine, MDTs in critical care medicine focus on implementation of guideline-directed care, prevention of iatrogenic harm, communication with patients and families, point-of-care decision-making, and the development of care plans. MDTs in acute cardiovascular care include physicians from cardiovascular medicine, critical care medicine, interventional cardiology, cardiac surgery, and advanced heart failure, in addition to nonphysician team members. In this document, we seek to describe the changes in patients in the cardiac intensive care unit, health care delivery, composition, logistics, outcomes, training, and future directions for MDTs involved in acute cardiovascular care. As a part of the comprehensive review, we performed a scoping of concepts of MDTs, acute hospital care, and cardiovascular conditions and procedures.

Pulmonary embolism response teams. A description of the first 36-month Australian experience

BACKGROUND

High/intermediate-risk pulmonary embolism (PE) confers increased risk of cardiovascular morbidity and mortality. International guidelines recommend the formation of a PE response team (PERT) for PE management because of the complexity of risk stratification and emerging treatment options. However, there are currently no available Australian data regarding outcomes of PE managed through a PERT.

AIMS

To analyse the clinical and outcome data of patients from an Australian centre with high/intermediate-risk PE requiring PERT-guided management.

METHODS

We performed a retrospective observational study of 75 consecutive patients with high/intermediate-risk PE who had PERT involvement, between August 2018 and July 2021. We recorded clinical and interventional data at the time of PERT and assessed patient outcomes up to 30 days from PERT initiation. We used unpaired t tests to compare right to left ventricular (RV/LV) ratios by computed tomography criteria or transthoracic echocardiogram (TTE) at baseline and after interventions.

RESULTS

Data were available for 74 patients. Initial computed tomography pulmonary angiography RV/LV ratio was increased at 1.65 ± 0.5 and decreased to 1.30 ± 0.29 following PERT-guided interventions (P < 0.001). TTE RV/LV ratio also decreased following PERT-guided management (1.09 ± 0.19 vs 0.93 ± 0.17; P < 0.001). 20% of patients had any bleeding complication, but two-thirds were mild, not requiring intervention. All-cause mortality was 6.8%, and all occurred within the first 7 days of admission.

CONCLUSION

The PERT model is feasible in a large Australian centre in managing complex and time-critical PE. Our data demonstrate outcomes comparable with existing published international PERT data. However, successful implementation at other Australian institutions may require adequate centre-specific resource availability and the presence of multispeciality input.

Evolution of Pulmonary Embolism Response Teams in the United States: A Review of the Literature

Pulmonary embolism (PE) is a significant cause of cardiovascular mortality, with varying presentations and management challenges. Traditional treatment approaches often differ, particularly for submassive/intermediate-risk PEs, because of the lack of clear guidelines and comparative data on treatment efficacy. The introduction of pulmonary embolism response teams (PERTs) aims to standardize and improve outcomes in acute PE management through multidisciplinary collaboration. This review examines the conception, evolution, and operational mechanisms of PERTs while providing a critical analysis of their implementation and efficacy using retrospective trials and recent randomized trials. The study also explores the integration of advanced therapeutic devices and treatment protocols facilitated by PERTs. PERT programs have significantly influenced the management of both massive and submassive PEs, with notable improvements in clinical outcomes such as decreased mortality and reduced length of hospital stay. The utilization of advanced therapies, including catheter-directed thrombolysis and mechanical thrombectomy, has increased under PERT guidance. Evidence from various studies, including those from the National PERT Consortium, underscores the benefits of these multidisciplinary teams in managing complex PE cases, despite some studies showing no significant difference in mortality. PERT programs have demonstrated potentials to reduce morbidity and mortality, streamlining the use of healthcare resources and fostering a model of sustainable practice across medical centers. PERT program implementation appears to have improved PE treatment protocols and innovated advanced therapy options, which will be further refined as they are employed in clinical practice. The continued expansion of the capabilities of PERTs and the forthcoming results from ongoing randomized trials are expected to further define and optimize management protocols for acute PEs.

The Current Evidence of Pulmonary Embolism Response Teams and Their Role in Future

Acute pulmonary embolism (PE) remains a critical medical condition requiring prompt and accurate management. The introduction and growing significance of pulmonary embolism response teams (PERT), also termed EXPERT-PE teams, signify a paradigm shift toward a collaborative, multidisciplinary approach in managing this complex entity. As the understanding of acute PE continues to evolve, PERTs stand as a linkage of optimized care, offering personalized and evidence-based management strategies for patients afflicted by this life-threatening condition. The evolving role of PERTs globally is evident in their increasing integration into the standard care pathways for acute PE. These teams have demonstrated benefits such as reducing time to diagnosis and treatment initiation, optimizing resource utilization, and improving patient outcomes.

Impact of the IR/DR Primary Specialty Certification on Scientific Research in the Field

Research is essential to the development, maintenance, and success of interventional radiology (IR) as a primary specialty. IR physicians must embrace a more sophisticated research approach toward the procedures we perform and the diseases we treat to accompany our elevated status. Identifying impactful research needs and directing a comprehensive research portfolio will anchor our position as an essential specialty within a thriving health care system. Doing so will ensure that this historic opportunity is maximized for the benefit of IR physicians, IR trainees, and, ultimately, IR patients.

Effect of a pulmonary embolism response team on the management and outcomes of patients with acute pulmonary embolism

OBJECTIVE

We aimed to evaluate the effects of a multidisciplinary pulmonary embolism (PE) response team (PERT) on the management and outcomes of patients with acute PE.

METHODS

We retrospectively reviewed all patients presenting to our institution with a diagnosis of PE from July 2020 to April 2022. The primary outcome measures were in-hospital mortality, major bleeding events defined by the International Society on Thrombosis and Haemostasis, and use of catheter-directed interventions (CDIs). The secondary outcome measures included 30-day and 12-month mortality, hospital and intensive care unit (ICU) lengths of stay, vasopressor requirement, and cardiac arrest. Continuous variables were assessed using the Mann-Whitney U test and categorical variables using the χ2 or Fisher exact test, as appropriate.

RESULTS

A total of 279 patients with acute PE were identified, of whom 79 (28%), 173 (62%), and 27 (10%) were considered to have low risk, intermediate risk, and high risk, respectively. The PERT was activated for 133 patients (47.7%). Saddle and main pulmonary artery embolisms (P < .001), right ventricular strain (P= .001), right ventricular dysfunction (P < .001), coexisting deep vein thrombosis (P < .001), and dyspnea as a presenting symptom (P = .008) were significantly associated with PERT activation. Patients evaluated by the PERT were more likely to undergo CDI (49% vs 27%; P < .001) across all risk groups and less likely to have an inferior vena cava filter placed (1% vs 5%; P = .04). PERT consultation showed numerical, but nonstatistically significant, trends toward reduced in-hospital (2% vs 5%; P = .2) and 30-day (2% vs 8%; P = .06) mortality but similar rates of 12-month mortality (7% vs 8%; P = .7). PERT activation was also associated with a trend toward reduced rates of major bleeding (2% vs 7%), cardiac arrest (2% vs 7%), and vasopressor requirement (9% vs 18%). PERT consultations decreased the median number of ICU days by one half; however, we did not observe any differences in the total hospital length of stay between the groups.

CONCLUSIONS

At our institution, PERT consultations were associated with significantly higher usage of CDIs and improved clinical outcomes, including reduced mortality and a lower rate of major bleeding events. PERT consultations were also associated with fewer ICU days, suggesting a possible economic benefit for implementing PERTs, although further research is needed to confirm that conclusion.

Comparative Outcomes of Catheter-Directed Thrombolysis Plus Systemic Anticoagulation Versus Systemic Anticoagulation Alone in the Management of Intermediate-Risk Pulmonary Embolism in a Systematic Review and Meta-Analysis

There are limited and conflicting data on the initial management of intermediate-risk (or submassive) pulmonary embolism (PE). This study sought to compare the outcomes of catheter-directed thrombolysis (CDT) in combination with systemic anticoagulation (SA) to SA alone. A systematic search was conducted in MEDLINE, EMBASE, PubMed, and the Cochrane databases from inception to March 1, 2023 for studies comparing the outcomes of CDT + SA versus SA alone in intermediate-risk PE. The outcomes were in-hospital, 30-day, 90-day, and 1-year mortality; bleeding; blood transfusion; right ventricular recovery; and length of stay. Random-effects models was used to calculate the pooled incidence and risk ratios (RRs) with 95% confidence intervals (CIs). A total of 15 (2 randomized and 13 observational) studies with 10,549 (2,310 CDT + SA and 8,239 SA alone) patients were included. Compared with SA, CDT + SA was associated with significantly lower in-hospital mortality (RR 0.41, 95% CI 0.30 to 0.56, p <0.001), 30-day mortality (RR 0.34, 95% CI 0.18 to 0.67, p = 0.002), 90-day mortality (RR 0.34, 95% CI 0.17 to 0.67, p = 0.002), and 1-year mortality (RR 0.58, 95% CI 0.34 to 0.97, p = 0.04). There were no significant differences between the 2 cohorts in the rates of major bleeding (RR 1.39, 95% CI 0.72 to 2.68, p = 0.56), minor bleeding (RR 1.83, 95% CI 0.97 to 3.46, p = 0.06), and blood transfusion (RR 0.34, 95% CI 0.10 to 1.15, p = 0.08). In conclusion, CDT + SA is associated with significantly lower short-term and long-term all-cause mortality, without any differences in major/minor bleeding, in patients with intermediate-risk PE.

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

BACKGROUND

Over 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.

METHODS

We 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.

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 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.

CONCLUSIONS

PERT 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.

REGISTRATION

Open Science Framework 10.17605/OSF.IO/SBFK9.

Effect of pulmonary embolism response team on advanced therapies administered: The University of Michigan experience

BACKGROUND

Pulmonary Embolism Response Teams (PERT) were employed at multiple institutions to bridge the gap between varied treatment options for acute PE and unclear evidence for optimal management. There is limited data regarding the impact of PERT on the use of advanced therapies and clinical outcomes.

METHODS

We performed a retrospective single-center cohort study comparing patients that presented to the ED with an acute PE before and after the creation of PERT in June 2017 at our institution. We assessed utilization of advanced therapies, LOS, and mortality.

RESULTS

A total of 817 patients (168 pre-PERT, 649 post-PERT) were evaluated in the ED with an acute PE between October 2016 and December 2019. Both groups were similar in demographics, comorbidities, and PESI score. There was a decrease in advanced therapy use (16 % vs. 7.5 %, p = 0.006) after PERT creation. Most notable decreases were in catheter-based therapies (8.5 % vs. 2.2 %, p = 0.008) and IVC filter placement (5.3 % vs. 3.2 %, p < 0.001). Median ICU LOS (2.5 days vs. 2.3 days, p = 0.55) and hospital LOS (3.1 vs. 3.0, p = 0.92) did not vary pre-PERT vs. post-PERT. In-hospital mortality (8.5 % vs. 5.0 %, p = 0.29) and 30-day all-cause mortality (1.2 % vs. 0.5 %, p = 0.28) were not different between the two groups as well.

CONCLUSION

At our institution, PERT was associated with a decrease in advanced therapies administered to acute PE patients without affecting mortality or LOS. Additional studies to assess impact of this multi-disciplinary care team model on interventional therapies and clinical outcomes for PE at a broader level are necessary.

Pulmonary Embolism Response Teams: Theory, Implementation, and Unanswered Questions

Pulmonary embolism (PE) continues to represent a significant health care burden and its incidence is steadily increasing worldwide. Constantly evolving therapeutic options and the rarity of randomized controlled trial data to drive clinical guidelines impose challenges on physicians caring for patients with PE. Recently, PE response teams have been developed and recommended to help address these issues by facilitating a consensus among local experts while advocating the management of acute PE according to each individual patient profile. In this review, we focus on the clinical challenges supporting the need for a PE response team, report the current evidence for their implementation, assess their impact on PE management and outcomes, and address unanswered questions and future directions.

Impact of pulmonary embolism response teams on acute pulmonary embolism: a systematic review and meta-analysis

BACKGROUND

The impact of pulmonary embolism response teams (PERTs) on treatment choice and outcomes of patients with acute pulmonary embolism (PE) is still uncertain.

OBJECTIVE

To determine the effect of PERTs in the management and outcomes of patients with PE.

METHODS

PubMed, Embase, Web of Science, CINAHL, WorldWideScience and MedRxiv were searched for original articles reporting PERT patient outcomes from 2009. Data were analysed using a random effects model.

RESULTS

16 studies comprising 3827 PERT patients and 3967 controls met inclusion criteria. The PERT group had more patients with intermediate and high-risk PE (66.2%) compared to the control group (48.5%). Meta-analysis demonstrated an increased risk of catheter-directed interventions, systemic thrombolysis and surgical embolectomy (odds ratio (OR) 2.10, 95% confidence interval (CI) 1.74-2.53; p<0.01), similar bleeding complications (OR 1.10, 95% CI 0.88-1.37) and decreased utilisation of inferior vena cava (IVC) filters (OR 0.71, 95% CI 0.58-0.88; p<0.01) in the PERT group. Furthermore, there was a nonsignificant trend towards decreased mortality (OR 0.87, 95% CI 0.71-1.07; p=0.19) with PERTs.

CONCLUSIONS

The PERT group showed an increased use of advanced therapies and a decreased utilisation of IVC filters. This was not associated with increased bleeding. Despite comprising more severe PE patients, there was a trend towards lower mortality in the PERT group.

Intermediate-Risk Pulmonary Embolism: A Review of Contemporary Diagnosis, Risk Stratification and Management

Pulmonary embolism (PE) can have a wide range of hemodynamic effects, from asymptomatic to a life-threatening medical emergency. Pulmonary embolism (PE) is associated with high mortality and requires careful risk stratification for individualized management. PE is divided into three risk categories: low risk, intermediate-risk, and high risk. In terms of initial therapeutic choice and long-term management, intermediate-risk (or submassive) PE remains the most challenging subtype. The definitions, classifications, risk stratification, and management options of intermediate-risk PE are discussed in this review.

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.

Meta-Analysis Comparing Catheter-Directed Thrombolysis Versus Systemic Anticoagulation Alone for Submassive Pulmonary Embolism

The optimal therapy for submassive pulmonary embolism (sPE), defined by right ventricular dysfunction without hemodynamic instability, is uncertain. We conducted a systematic review and meta-analysis to compare the outcomes of catheter-directed thrombolysis (CDT) versus systemic anticoagulation (SA) alone in patients with sPE. We searched PubMed, EMBASE, Cochrane, ClinicalTrials.gov, and Google Scholar (from inception through May 2022) for studies comparing outcomes of CDT versus SA in sPE. Studies were identified, and data were extracted by 2 independent reviewers. We used a random-effects model to calculate risk ratios (RRs) with 95% confidence intervals (CIs). Outcomes included in-hospital, 30-day, 90-day, and 1-year mortality, major and minor bleeding, and need for blood transfusion. A total of 12 studies (1 randomized, 11 observational) with 9,789 patients were included. Compared with SA, CDT was associated with significantly lower in-hospital mortality (RR 0.41, 95% CI 0.30 to 0.56, p <0.00001), 30-day mortality (RR 0.37, 95% CI 0.18 to 0.73, p = 0.004), 90-day mortality (RR 0.36, 95% CI 0.17 to 0.72, p = 0.004), and a tendency toward lower 1-year mortality (RR 0.56, 95% CI 0.29 to 1.05, p = 0.07). The risks of major bleeding (RR 1.31, 95% CI 0.57 to 3.01, p = 0.53), minor bleeding (RR 1.67, 95% CI 0.77 to 3.63, p = 0.20), and the rates of blood transfusion (RR 0.34, 95% CI 0.10 to 1.15, p = 0.08) were similar between the 2 strategies. In conclusion, in patients with sPE, CDT is associated with significantly lower in-hospital, 30-day, and 90-day mortality and a tendency toward lower 1-year mortality with similar bleeding rates compared with SA. This study expands the evidence supporting CDT as first-line therapy for sPE, and randomized controlled trials are indicated to confirm our findings.

Endovascular Management of Venous Thromboembolic Disease in the Oncologic Patient Population

PURPOSE OF REVIEW

Venous thromboembolic disease causes significant mortality and morbidity in the oncologic patient population. Recently, minimally invasive endovascular technologies have been developed as an adjunct to antithrombotic therapy for the management of DVT and PE. The current and potential roles for endovascular treatment of cancer-associated venous thromboembolism (VTE) will be reviewed in this article.

RECENT FINDINGS

The recent NCCN guidelines recommend endovascular therapy in patients eligible for therapeutic anticoagulation who present with life-, organ-, or limb-threatening thrombosis. However, symptomatic non-life-threatening VTE can negatively affect QOL and physical function, both of which have prognostic implications in the cancer population. Endovascular therapies have been shown to improve physical function and QOL in prospective trials performed in a non-oncologic patient population as well as small retrospective studies in the cancer population. In addition to treating life- and limb-threatening thrombosis, endovascular therapy for VTE can improve QOL and physical function in comparison to anticoagulation alone. Prospective trials are warranted to assess the benefit of endovascular therapy for quality of life-years, performance status, and overall survival in the oncologic patient population.

Vancouver General Hospital Pulmonary Embolism Response Team (VGH PERT): initial three-year experience

PURPOSE

Clinical equipoise exists with the use of novel reperfusion therapies such as catheter-directed thrombolysis in the management of patients presenting to hospital with high risk pulmonary embolism (PE). Therapeutic options rely on clinical presentation, patient factors, physician preference, and institutional availability. We established a Pulmonary Embolism Response Team (PERT) to provide urgent assessment and multidisciplinary care for patients presenting to our institution with high-risk PE.

METHODS

Data were retrospectively collected from PERT activations between January 2016 and December 2018. Chi square tests were used to determine differences in mortality across the three years of study. Logistic regression was used to evaluate 30- and 90-day mortality and occurrence of major bleeds between those receiving anticoagulation alone (AC) and those receiving advanced reperfusion therapy (ART).

RESULTS

There were 128 PERT activations over three years, the majority originating from the emergency department. Eighty-five percent of activations were for submassive PE, with 56% of all activations assessed as submassive-high risk. Fifteen patients (12%) presented with massive PE. Advanced reperfusion therapy was used in 29 (23%) patients, of whom 25 (20%) received catheter-directed thrombolysis. There was an increased risk of major bleeding in the ART group compared with in the AC group (odds ratio [OR], 17.9; 95% confidence interval [CI], 4.1 to 125.0; P < 0.001), but no increased risk of mortality at 30 days (OR, 2.1; 95% CI, 0.4 to 9.1; P = 0.3). The 30-day mortality rate was 7.8%.

CONCLUSION

We describe the first Canadian PERT, a multidisciplinary team aimed at providing urgent individualized care for patients with high-risk PE. Further research is necessary to determine whether a PERT improves clinical outcomes.

First year experience of a pulmonary embolism response team with comparisons of outcomes between catheter directed therapy versus standard anticoagulation

Objectives: The Pulmonary Embolism Response Team (PERT) model is now widely adopted in many institutions to provide multidisciplinary care for patients with acute pulmonary embolism (PE). However, descriptive experiences of PERT operations and studies on clinical outcomes remain limited.Methods: We performed a retrospective review of PERT activations at an academic tertiary care center, with secondary aims to study outcomes associated with performing catheter directed therapies (CDT).Results: The intermediate high-risk PE category was most frequent (n = 40, 76.9%) among the 52 total cases evaluated during the study period. There was one in-hospital mortality, associated with hospice admission for a non-PE diagnosis. Six patients (11.5%) experienced a bleeding complication of any severity. Anticoagulation (AC) alone was recommended in 30 patients (57.7%) and CDT was performed in 16 patients (30.8%). There were no significant differences in patient characteristics or disease severity between patients in the AC group versus the CDT group, except for a higher prevalence of malignancy in the AC group (p = 0.037). Patients who underwent CDT demonstrated a lower, albeit non-significant, median intensive care unit (ICU) length of stay (LOS) (3 vs. 4 days, p = 0.34) and hospital LOS (4 vs. 5 days, p = 0.25), as compared to patients receiving AC alone. Bleeding rates were similar between the two groups (6.7% vs. 6.3%, p = 1.0).Conclusions: Adoption of the PERT model at an academic tertiary care center was associated with acceptably low rates of mortality and bleeding, similar to other published studies. Performing CDT in select patients under PERT consultation may be associated with shorter ICU and hospital LOS; however, larger studies are needed to validate this finding.

Impact of Multidisciplinary Pulmonary Embolism Response Team Availability on Management and Outcomes

Treatment strategies for complex patients with pulmonary embolism (PE) are often debated given patient heterogeneity, multitude of available treatment modalities, and lack of consensus guidelines. Although multidisciplinary Pulmonary Embolism Response Teams (PERT) are emerging to address this lack of consensus, their impact on patient outcomes is not entirely clear. This analysis was conducted to compare outcomes of all patients with PE before and after PERT availability. We analyzed all adult patients admitted with acute PE diagnosed on computed tomography scans in the 18 months before and after the institution of PERT at a large tertiary care hospital. Among 769 consecutive inpatients with PE, PERT era patients had lower rates of major or clinically relevant nonmajor bleeding (17.0% vs 8.3%, p = 0.002), shorter time-to-therapeutic anticoagulation (16.3 hour vs 12.6 hour, p = 0.009) and decreased use of inferior vena cava filters (22.2% vs 16.4%, p = 0.004). There was an increase in the use of thrombolytics/catheter-based strategies, however, this did not achieve statistical significance (p = 0.07). There was a significant decrease in 30-day/inpatient mortality (8.5% vs 4.7%, p = 0.03). These differences in outcomes were more pronounced in intermediate and high-risk patients (mortality 10.0% vs 5.3%, p = 0.02). The availability of multidisciplinary PERT was associated with improved outcomes including 30-day mortality. Patients with higher severity of PE seemed to derive most benefit from PERT availability.

Rationale for catheter-based therapies in acute pulmonary embolism

Pulmonary embolism (PE) is a common disease resulting in significant morbidity and mortality. High-risk features of PE are hypotension or shock, and early reperfusion is warranted to unload the strained right ventricle and improve clinical outcomes. Currently, systemic thrombolysis (ST) is the standard of care but is associated with bleeding complications. Catheter-based therapies (CDT) have emerged as a promising alternative having demonstrated to be equally effective while having a lower risk of bleeding. Several CDT are currently available, some combining mechanical properties with low-dose thrombolytics. Recent guidelines suggest that CDT may be considered in patients with high-risk PE who have high bleeding risk, after failed ST, or in patients with rapid haemodynamic deterioration as bail-out before ST can be effective, depending on local availability and expertise. In haemodynamically stable patients with right ventricular (RV) dysfunction (intermediate-risk PE), CDT may be considered if clinical deterioration occurs after starting anticoagulation and relative contraindications for ST due to bleeding risk exist. Decision on treatment modality should follow a risk-benefit analysis on a case by case base, weighing the risk of PE-related complications; i.e. haemodynamic deterioration vs. bleeding. As timely initiation of treatment is warranted to prevent early mortality, bleeding risk factors should be assessed at an early stage in all patients with acute PE and signs of RV dysfunction. To ensure optimal management of complex cases of PE and assess a potential CDT strategy, a multidisciplinary approach is recommended. A dedicated Pulmonary Embolism Response Team may optimize this process.

Interventional Therapies for Acute Pulmonary Embolism: Current Status and Principles for the Development of Novel Evidence: A Scientific Statement From the American Heart Association

Pulmonary embolism (PE) represents the third leading cause of cardiovascular mortality. The technological landscape for management of acute intermediate- and high-risk PE is rapidly evolving. Two interventional devices using pharmacomechanical means to recanalize the pulmonary arteries have recently been cleared by the US Food and Drug Administration for marketing, and several others are in various stages of development. The purpose of this document is to clarify the current state of endovascular interventional therapy for acute PE and to provide considerations for evidence development for new devices that will define which patients with PE would derive the greatest net benefit from their use in various clinical settings. First, definitions and limitations of commonly used risk stratification tools for PE are reviewed. An adjudication of risks and benefits of available interventional therapies for PE follows. Next, considerations for optimal future evidence development in this field are presented in the context of the current US regulatory framework. Finally, the document concludes with a discussion of the pros and cons of the rapidly expanding PE response team model of care delivery.

Identification, diagnosis, treatment, and in-hospital outcomes of acute pulmonary embolism: Results from a single integrated health system

BACKGROUND

Although the high-risk acute pulmonary embolism (PE) population has been described, little is known about the contemporary inpatient experience and practice patterns of the PE population as a whole.

METHODS

All patients with a diagnosis of acute PE from January 1, 2016, to June 30, 2017 within our academic, multihospital health system were retrospectively identified using International Classification of Diseases, 10th Revision, codes, and data were manually abstracted by 2 clinical investigators. Descriptive analyses were performed according to clinical risk stratification categories from the European Society of Cardiology.

RESULTS

Of 829 total patients, 372 (44.8%) patients had intermediate or high-risk PE. Mean age was 62.1 years old, and 42.1% of patients had a history of malignancy. One hundred fifty-three (18.5%) patients had an acute PE during a hospitalization for another indication. A total of 6.0% underwent invasive PE therapies, 26.1% required intensive care unit admission, and 9.0% experienced in-hospital death or hospice discharge. In a subgroup description, patients who developed acute PE during a hospitalization for another indication had a higher incidence of incomplete risk stratification and a higher mortality (9.8%) than the primary cohort. Mortality was attributed to PE in 48.4% of cases.

CONCLUSIONS

This contemporary description of acute PE managed at a single large, multihospital academic health system highlights substantial health care utilization and high mortality despite the available of advanced therapeutics. Additional work is needed to standardize care for the heterogeneous PE population to ensure appropriate allocation of resources and improved outcomes for all PE patients.

Pulmonary embolism critical care update: prognosis, treatment, and research gaps

PURPOSE OF REVIEW

We provide a timely update on treatment care issues facing clinicians and patients with acute pulmonary embolism accompanied by either right ventricular strain (sub-massive pulmonary embolism) or shock (massive pulmonary embolism).

RECENT FINDINGS

Care and research changes over the last several years have resulted in four important trends: more consensus and accuracy in the way acute pulmonary embolism severity is described and communicated among acute care clinicians and researchers, increased availability and use of risk prediction scoring systems, increased use of advanced invasive therapy in the setting of severe right ventricular dysfunction, and emergence of multidisciplinary pulmonary embolism response teams to guide standard care decision-making.

SUMMARY

Pulmonary embolism with shock should be treated with either systemic or catheter-based thrombolytic therapy in the absence of contraindications. Patients with sub-massive pulmonary embolism accompanied by right heart dysfunction who are treated with thrombolytic therapy likely will experience more rapid improvement in RV function and are less likely to progress to hemodynamic decompensation. This comes, however, with an increased risk of major bleeding. Our recommendation is to consider catheter-based or systemic fibrinolytic therapy in sub-massive pulmonary embolism cases where patients demonstrate high-risk features such as: severe RV strain on echo or CT, and importantly worsening over time trends in pulse, SBP, and oxygenation despite anticoagulation. Understanding the impact of advanced therapy beyond standard anticoagulation on patient-centered outcomes, such as functional status and quality of life represent a research knowledge gap.

Hemodynamic decompensation in normotensive patients admitted to the ICU with pulmonary embolism

PURPOSE

Many normotensive patients with acute pulmonary embolism (PE) are admitted to an intensive care unit (ICU) to monitor for hemodynamic decompensation. We investigated the incidence and causes of early hemodynamic decompensation in normotensive patients admitted to an ICU with PE.

MATERIALS AND METHODS

This was a single-center, retrospective study of normotensive patients admitted to an ICU with primary diagnosis of PE between 2010 and 2017. The primary outcome was hemodynamic decompensation, defined as need for vasopressors within 48 h of ICU admission.

RESULTS

Of 293 patients included in the study, hemodynamic decompensation occurred in 8 patients (2.7%). The two most common precipitants of hemodynamic decompensation were acute hemorrhage and PE-related right ventricular dysfunction - each contributing to hemodynamic decompensation in 3 patients.

CONCLUSIONS

Among patients admitted to the ICU with acute normotensive PE, early hemodynamic decompensation was rare. In patients who experienced decompensation, major bleeding and thrombotic complications were equally likely to have been the precipitant- highlighting the risks of diagnostic anchoring in this population. As our results suggest that ICU-level care may not be necessary for many of these patients, additional tools are needed to assist in the triage of normotensive patients with PE.

Pulmonary embolism response teams: Purpose, evidence for efficacy, and future research directions

Pulmonary embolism (PE) is a major cause of morbidity and mortality in the United States. Although new therapeutic tools and strategies have recently been developed for the diagnosis and treatment of patients with PE, the outcomes for patients who present with massive or high-risk PE remain dismal. To address this crisis, pulmonary embolism response teams (PERTs) are being created around the world in an effort to immediately and simultaneously engage multiple specialists to determine the best course of action and coordinate the clinical care for patients with acute PE. The scope of this review is to describe the PERT model and purpose, present the structure and organization, examine the available evidence for efficacy and usefulness, and propose future directions for research that is needed to demonstrate the value of PERT and determine if this multidisciplinary approach represents a new standard of care.

The implementation of a pulmonary embolism response team in the management of intermediate- or high-risk pulmonary embolism

BACKGROUND

Massive and submassive pulmonary embolism (PE) can be life-threatening. Treatment options include anticoagulation, fibrinolysis, catheter-directed or open surgical thrombus removal, and extracorporeal membrane oxygenation. With increasing patient complexity and advanced therapeutic options, the approach to optimal care for patients with intermediate- to high-risk PE is not clearly established. Multidisciplinary, rapid response teams can optimize risk stratification and expedite management. A PE response team (PERT) composed of specialists from cardiology, vascular surgery, emergency medicine, pulmonary and critical care, interventional radiology, cardiac surgery, hospital medicine, and pharmacy was created at our institution. The team is tasked with evaluating and treating patients with massive and submassive PE by use of a risk stratification and treatment algorithm. We describe our initial experience with this approach.

METHODS

The records of patients treated by the PERT since inception in October 2015 through May 2017 were reviewed (intervention group). The diagnoses codes of the PERT patients were retrieved from the Vizient database. A retrospective control cohort group was created using these specific diagnoses and a matching set of demographics (age, sex), Medicare Severity Diagnosis Related Group, admission severity of illness, and admission risk of mortality. Statistical analysis was performed using the Fisher exact test, the Pearson χ² statistic, Student t-test, and Cochran-Cox approximation. P < .05 was considered significant.

RESULTS

During the time interval, 77 patients with massive or submassive PE were treated by PERT activation; 992 patients included in the control group were treated at the discretion of an attending physician without use of the algorithm from October 2013 to 2016. Both groups had similar demographics, similar distribution of risk of mortality and severity of illness, and similar average Medicare Severity Diagnosis Related Group weighting. There was no statistically significant difference in the mortality rate between the two groups. The PERT group had significantly lower intensive care unit stay and overall length of stay. No difference was seen in direct cost between the two groups despite higher use of interventional treatment modalities in the PERT group.

CONCLUSIONS

In our institution, assembly of a dedicated team to treat patients with massive or submassive PE according to a clinical algorithm resulted in expedited treatment and reduced variation of care. Intensive care unit stay and overall length of stay were reduced by this approach, with no impact on direct cost despite the use of advanced modalities of treatment. We believe that this paradigm can be of potential value in other disease entities, particularly when multiple disciplines are involved.

Contemporary Management and Outcomes of Patients with Massive and Submassive Pulmonary Embolism

BACKGROUND

Few contemporary studies have assessed the management and outcomes of patients with massive and submassive pulmonary embolism. Given advances in therapy, we report contemporary practice patterns and event rates among these patients.

METHODS

We analyzed a prospective database of patients with massive and submassive pulmonary embolism. We report clinical characteristics, therapies, and outcomes stratified by pulmonary embolism type. Treatment escalation beyond systemic anticoagulation was defined as advanced therapy. Cox proportional hazards regression was used to identify predictors of 90-day mortality.

RESULTS

Among 338 patients, 46 (13.6%) presented with massive and 292 (86.4%) with submassive pulmonary embolism. The average age was 63 ± 15 years, 49.9% were female, 32.0% had malignancy, and 21.9% had recent surgery. Massive pulmonary embolism patients received advanced therapy in 71.7% (30.4% systemic thrombolysis, 17.4% catheter-directed thrombolysis, 15.2% surgical embolectomy) and had greater 90-day mortality rates compared with submassive pulmonary embolism patients (41.3% vs 12.3%, respectively; P < .01). Most massive pulmonary embolism deaths (78.9%) occurred in-hospital, whereas mortality risk persisted after discharge for submassive pulmonary embolism. After multivariable adjustment, massive pulmonary embolism was associated with a 5.23-fold greater hazard of mortality (95% confidence interval, 2.70-10.13; P < .01). Advanced therapies among all pulmonary embolism patients were associated with a 61% reduction in mortality (95% confidence interval, 0.20-0.76; P < .01).

CONCLUSIONS

Among contemporary massive and submassive pulmonary embolism patients, mortality remains substantial. Advanced therapies were frequently utilized and independently associated with lower mortality. Further investigation is needed to determine how to improve outcomes among these high-risk patients, including the optimal use of advanced therapies.

Pulmonary Embolism Response Teams: A Novel Approach for the Care of Complex Patients With Pulmonary Embolism

Pulmonary embolism represents the third most common cause of cardiovascular death in the United States. Reperfusion therapeutic strategies such as systemic thrombolysis, catheter directed therapies, surgical pulmonary embolectomy, and cardiopulmonary support devices are currently available for patients with high- and intermediate-high–risk pulmonary embolism. However, deciding on optimal therapy may be challenging. Pulmonary embolism response teams have been designed to facilitate multidisciplinary decision-making with the goal to improve quality of care for complex cases with pulmonary embolism. Herein, we discuss the current role and strategies on how to leverage the strengths from pulmonary embolism response teams, its possible worldwide adoption, and implementation to improve survival and change the paradigm in the care of a potentially deadly disease.

The future of anesthesia for interventional radiology

PURPOSE OF REVIEW

To review novel procedures in interventional radiology and describe anesthetic implications.

RECENT FINDINGS

Noninvasive treatment options for patients who are nonsurgical candidates are on the rise. The complication rate for patients receiving anesthesia in the interventional radiology suite is higher than other nonoperating room anesthetizing locations. The investigative use of catheter-directed thrombolysis for acute submassive pulmonary embolism will likely lead to an increased demand for anesthesia assistance. Treatment of prostate cancer with high-intensity focused ultrasound with MRI guidance is an alternative to surgical treatment and has unique anesthetic implications. With advances in technology, interventional radiologists have expanded their treatment armamentarium for benign and malignant bony lesions and thus the need for anesthesia assistance.

SUMMARY

As the complexity of procedures and patients increases, the demand for anesthesia support in interventional radiology rises. As novel techniques are being developed, anesthesiologists must be mindful of the increased complication rate in interventional radiology and work in a multidisciplinary approach to improve patient safety.

Aggressive Treatment of Intermediate-Risk Patients with Acute Symptomatic Pulmonary Embolism

Contemporary studies of acute pulmonary embolism (PE) have evaluated the role of thrombolytics in intermediate-risk PE. Significant findings are that thrombolytic therapy may prevent hemodynamic deterioration and all-cause mortality but increases major bleeding. Benefits and harms are finely balanced with no convincing net benefit from thrombolytic therapy among unselected patients. Among patients with intermediate risk PE, additional prognostic factors or subtle hemodynamic changes might alter the risk-benefit assessment in favor of thrombolytic therapy before obvious hemodynamic instability.

Contemporary Management of the High-Risk Pulmonary Embolism: The Clot Thickens

Pulmonary embolism (PE) is a common disease process encountered in the acute care setting. It presents on a spectrum of severity with the most severe presentations carrying a substantial risk of morbidity and mortality. In recent years, a wide range of competing treatment strategies have been proposed for the high-risk PE including new catheter-based and extracorporeal techniques, and management has become more challenging. There is currently no consensus as to the optimal approach to treatment. Contemporary management decisions are informed by the balance between the risk of deterioration and the risk of harm from intervention, within the available resources. This review will summarize the current evidence to better inform clinical decision-making in high-risk PE and highlight future directions in management.

The impact of a multi-specialty team for high risk pulmonary embolism on resident and fellow education

The impact of the Pulmonary Embolism Response Team (PERT) model on trainee physician education and autonomy over the management of high risk pulmonary embolism (PE) is unknown. A resident and fellow questionnaire was administered 1 year after PERT implementation. A total of 122 physicians were surveyed, and 73 responded. Even after 12 months of interacting with the PERT consultative service, and having formal instruction in high risk PE management, 51% and 49% of respondents underestimated the true 3-month mortality for sub-massive and massive PE, respectively, and 44% were unaware of a common physical exam finding in patients with PE. Comparing before and after PERT implementation, physicians perceived enhanced confidence in identifying ( p<0.001), and managing ( p=0.003) sub-massive/massive PE, enhanced confidence in treating patients appropriately with systemic thrombolysis ( p=0.04), and increased knowledge of indications for systemic thrombolysis and surgical embolectomy ( p=0.043 and p<0.001, respectively). Respondents self-reported an increased fund of knowledge of high risk PE pathophysiology (77%), and the perception that a multi-disciplinary team improves the care of patients with high risk PE (89%). Seventy-one percent of respondents favored broad implementation of a PERT similar to an acute myocardial infarction team. Overall, trainee physicians at a large institution perceived an enhanced educational experience while managing PE following PERT implementation, believing the team concept is better for patient care.

Patient Assessment: Clinical Presentation, Imaging Diagnosis, Risk Stratification, and the Role of Pulmonary Embolism Response Team

Pulmonary embolism (PE) is currently the third leading cause of death and moreover is likely underdiagnosed. PE remains the most common preventable cause of hospital deaths in the United States, which may be attributable to its diagnostic challenges. Although difficult to diagnose, patient mortality rates are time-dependent, and thus, the suspicion and diagnosis of PE in a timely manner is imperative. Diagnosis based on several criteria which may dictate imaging workup as well as laboratory tests and clinical parameters are discussed. The evolution of treatment guidelines via various clinical trials and recommendations is outlined, setting the stage for the use of fibrinolytics, whether systemic or catheter directed. Treatment, including fibrinolytics, is predicated on patient triage into three large categories-massive, submassive, or low-risk PE. Additionally, a relatively new concept of a multidisciplinary team composed of several subspecialty experts known as the PE response team (PERT) is discussed. PERT's timely and unified recommendations have been shown to optimize care and decrease mortality while tailoring treatment to each individual afflicted by PE.

Acute pulmonary embolism: endovascular therapy

Pulmonary embolism (PE) is a leading cause of morbidity and mortality worldwide. PE is a complex disease with a highly variable presentation and the available treatment options for PE are expanding rapidly. Anticoagulation (AC), systemic lysis, surgery, and catheter-directed thrombolysis (CDT) play important roles in treating patients with PE. Thus, a multidisciplinary approach to diagnosis, risk stratification, and therapy is required to determine which treatment option is best for a given patient with this complex disease.

Multidisciplinary approach to the management of pulmonary embolism patients: the pulmonary embolism response team (PERT)

Pulmonary embolism (PE) is a potentially fatal disease with a broad range of treatment options that spans multiple specialties. The rapid evolution and expansion of novel therapies to treat PE make it a disease process that is well suited to a multidisciplinary approach. In order to facilitate a rapid, robust response to the diagnosis of PE, some hospitals have established multidisciplinary pulmonary embolism response teams (PERTs). The PERT model is based on existing multidisciplinary teams such as heart teams and rapid response teams. A PERT is composed of clinicians from the range of specialties involved in the treatment of PE, including pulmonology critical care, interventional radiology, cardiology, and cardiothoracic surgery among others. A PERT is a 24/7 consult service that is able to provide expert advice on the initial management of PE patients and convene in real time to develop a consensus treatment plan specifically tailored to the needs of a particular patient and consistent with the capabilities of the institution. In this review, we discuss the rationale for establishing a PERT and its potential benefits. We discuss considerations in forming a PERT and present case studies of several PERTs currently in operation at different institutions. We also discuss potential difficulties in forming a PERT and review evidence that has been generated by some of the PERTs that have been in operation the longest.