Massive PE: Ecmo, Lysis, CDT or Embolectomy. When and What? Mahir - - PowerPoint PPT Presentation

Massive PE: Ecmo, Lysis, CDT or

• Embolectomy. When and What?

Mahir Elder, MD, FACC, SCAI

Clinical Professor of medicine Wayne State University-School of medicine Clinical Professor of medicine Michigan State University- Osteopathic School

Disclosures:

Proctor Abiomed Proctor BTG

Pulmonary Embolism

Patient risk stratification (per AHA 2011 guidelines)

Massive PE Submassive PE Minor/Nonmassive PE

High risk Moderate risk Low risk

• Sustained hypotension

(systolic BP <90 mmHg for 15 min)

• Inotropic support
• Pulselessness
• Persistent profound

bradycardia (HR <40 bpm with signs or symptoms of shock)

• Systemically normotensive

(systolic BP 90 mmHg)

• RV dysfunction
• Myocardial necrosis
• Systemically normotensive

(systolic BP 90 mmHg)

• No RV dysfunction
• No myocardial necrosis

RV dysfunction

• RV/LV ratio > 0.9 or RV systolic dysfunction on echo
• RV/LV ratio > 0.9 on CT
• Elevation of BNP (>90 pg/mL)
• Elevation of NTpro-BNP (>500 pg/mL)
• ECG changes

Jaff et al. Management of massive and submassive pulmonary embolism, iliofemoral deep vein thrombosis, and chronic thromboembolic pulmonary hypertension: A scientific statement from the American Heart Association. Circulation 2011;123(16):1788-1830. Massive 5% Submassive 40% Nonmassive 55% Goldhaber SZ, Visani L, De Rosa M, et al. for ICOPER. Acute pulmonary embolism; clinical outcomes in the International Cooperative Pulmonary Embolism Registry. Lancet 1999;353:1386-1389

Key factors contributing to HD collapse in acute PE

Eur Heart J. 2014 Nov 14;35(43):3033-69

PE with Shock or Hypotension

European Heart Journal (2014)

Recommendations Class Level PE with shock hypotension (high risk) It is recommended to initiate intravenous anticoagulation with UFH without delay in patients with high-risk PE. I C Thrombolytic therapy is recommended. I B Surgical pulmonary embolectomy is recommended for patients in whom thrombolysis is contraindicated or has failed. I C Percutaneous catheter-directed treatment should be considered as an alternative to surgical pulmonary embolectomy for patients in whom full-dose systemic thrombolysis is contraindicated or has failed. IIa C

Treatment options for Massive PE:

• Surgical intervention
• Systemic anticoagulation
• Systemic thrombolysis
• Catheter directed lysis

RV mechanical support

Surgical embolectomy

• Massive or submassive PE with contraindication to lysis
• Acute PE with RA thrombus or paradoxical embolism
• Performed in only 1% of PE patients with massive PE and cardiogenic shock (based
• n the two largest PE registries)1,2
• In 2013, nationwide large-sample analysis reported 27.2% inpatient mortality1
• In 2018, mortality rate of patients treated with ECMO and surgical was 29%.2

1Goldhaber et al. Lancet 1999;353:1386-1389. 2Kasper et al. J Am Coll Cardiol 1997;30:1165-1171 3 Kilic et al. J Thorac Cardiovasc Surg 2013;145:373-377 4European heart

journal 39.47 (2018): 4196-4204

J Thorac Cardiovasc Surg. 2018 Aug;156(2):672-681

VA ECMO is effective method to triage and optimize massive PE to recovery or intervention

Perfusion, 34(1), 22-28.

Surgical embolectomy, (4) 31%

Thrombectomy

• AngioVac
• AngioJet
• Inari
• Penumbra
• EKOS*

Mechanical RV Circulatory Support

• Impella RP
• Tandem Heart-Protek
• ECMO: V-A & V-V

Impella RP

Indicated for providing circulatory assistance for up to 14 days in patients with a body surface area ≥ 1.5 m2 who develop acute right heart failure or decompensation following LVAD, myocardial infarction, heart transplant, or

• pen-heart surgery.

RP Impella Sheath and Insertion

FDA Letter

4/2 /23 pa pati tients (17 (17%) ) sur surviv ival no no pa patie ients wit ith PE Late ins nsertio ion

FDA Letter

4/2 /23 pa pati tients (17 (17%) ) sur surviv ival no no pa patie ients wit ith PE Late ins nsertio ion

Impella RP PMA study :18 –month Post approval study (42patients) – two categories Salvage support: > 48 hrs in cardiogenic shock from RV failure

• ut of hospital arrest or transferred from multiple hospitals

lifesaving for sickest patients Recover right protocol-73% survival rate ACC March 18 , 2019

In patients with PE and RV shock, Impella RP device resulted in immediate hemodynamic benefit with reversal of shock and favorable survival to

• discharge. These findings support its probable benefit in this gravely ill

patient population.

J Interv Cardiol. 2018 Mar 7.

Massive PE & RV Cardiogenic shock refractory to inotropes treated with RP Impella as bridge to recovery. Prior to Impella RP: all patients treated with EKOS/CDT.

In patients with PE and RV shock, Impella RP device resulted in immediate hemodynamic benefit with reversal of shock and favorable survival to

• discharge. These findings support its probable benefit in this gravely ill

patient population.

J Interv Cardiol. 2018 Mar 7.

Massive PE & RV Cardiogenic shock refractory to inotropes treated with RP Impella as bridge to recovery. Prior to Impella RP: all patients treated with EKOS/CDT.

All patients survived to discharge.

Tandem Heart

Common uses in Acute RV failure

• Acute PE
• RV infarction
• RV dysfunction post-LVAD
• ARDS

Double or Single Venous Access

• In-flow from right atrium
• Out-flow into pulmonary artery

ECMO

• V-V ECMO
• Refractory respiratory failure
• Modest cardiac or hemodynamic effects
• RV and LV pre- and after-load largely unaffected
• Potential decrease in RV afterload → improved oxygenation
• V-A ECMO
• Heart and Lung support
• ↓RV pre-load and pulmonary flow
• ↑ LV afterload and ↓ arterial pulse pressure

V-A and V-VA ECMO

Simon J. Finney Eur Respir Rev 2014;23:379-389

Impella RP Tandem Heart

(Protek)

V-V ECMO V-A ECMO

Mechanism Micro-axial Centrifugal Centrifugal Centrifugal Cannula Size 24F Peel away, 9Fr catheter 29-31Fr Dual Lumen 31Fr Dual lumen or 18-22 Fr. Single in/outflow 14-16 Fr Arterial 18-21 Fr Venous Insertion Technique Single femoral vein, 9Fr catheter remains in vein Dual lumen IJ IJ dual lumen or fem vein and IJ Peripheral or Central Hemodynamic Support >4 L/min maximum flow Up to 5 L/min Up to 4.5L/ min (flow rate )* 5-7 L/min Implantation Time + +++ + ++ Device Preparation Time + ++ +++ +++ Anticoagulation ++ +++ +++ +++ Post Implant Management + ++ +++ +++ Hemolysis Risk + + ++ ++ Respiratory Support No Yes Yes Yes Risk of Hemolysis + + ++ ++ Pros Single access site BiVAD possible with escalation ++Ambulate (neck) + cath into PA +Can add Oxygenator Oxygenation -+++ Can convert to V-A Hemodynamic support Oxygenation +++ Cons No intrinsic oxygenator Long insertion time High Transfusion rates Transseptal (LA-FA bypass) *No Hemodynamic support LV Distension ( against flow) Vascular complications, SIRS Transfusion (bleed) 23Fr

Case

Case # presentation

• Chief Complaint

53 year old female who presented with exertional dyspnea for 3 days.

• History of Present Illness

Recent admission for lower extremity cellulitis. finished two weeks course of cefipime and bactrim.

• Physical examination

Unremarkable aside of sinus tachycardia and tachypenic

Electrocardiogram

+ Sinus tachycardia. + Inverted T waves in V1-V3.

• Left axis.
• Lack of classic S1Q3T3.
• No new RBBB.
• Creatinine 1.1 mg/dL, normal electrolytes.
• Troponin I- 1.34 ng.
• BNP- 725
• Lactic Acid 2.9 mmoles/L.
• CBC:
• WBC 8.7 in mm3.
• Hb 10.5 gr%.
• PLT 252 in mm3.
• Risk stratification:
• PESI 109- moderate range.
• Modified PESI 8.9% risk of index admission

mortality.

Relevant lab results

Echo

CT Scan and Pulmonary angiogram

Severe RV enlargement: RV/LV ratio >> 0.9.

Right heart cath- First day of admission

• RA: 16/18/17 mmHg.
• RV: 40/10/20 mmHg.
• PA: 39/23/30 mmHg.
• PAPI: PA pulse pressure / mean RA = 0.94.
• Cardiac output: 4.7 L/min.
• Cardiac index: 2.15 L/min/m2.

Catheter mediated thrombolysis- Two EKOS catheter based ultrasonic filaments were placed into the right and left main pulmonary arteries.

EKOS Endovascular System

TWO 12 cm EKOS catheter - tPA infusion at 2 mg/hr (12 hr) followed by 1 mg/hr. Heparin administered systemically at 500 U/hr.

Hemodynamic deterioration- Third day of admission

• Systolic blood pressure 86 mmHg / Heart rate 110 min
• Reduced urine output.
• Respiratory rate 36 min.
• Hypoxic: SPO2 82% → intubated
• Right heart catheterization:
• RA: 19/24/23 mmHg.
• RV: 42/11/26 mmHg.
• PA: 41/28/33 mmHg.
• PAPI: PA pulse pressure / mean RA = 0.56.
• VA ECMO inserted

ECMO for 6 days

• Marked hemodynamic improvement.
• Right heart catheterization before ECMO removal:
• RA 18/22/21 mmHg.
• RV 49/14/20 mmHg.
• PA 48/31/37 mmHg.
• PAPI: 0.81
• Patient was discharged after 20 days of admission.

Echocardiography

Before RV Support: Severe RV dilatation with reduction in FAC RV Support day 4: Severe RV dilatation with mild improvement in FAC Post RV Support : Severe RV dilatation with significant improvement in FAC

Proposed algorithm Massive PE

• Surgical embolectomy –if experienced center with rapid access
• TPA- systemic : Reassess hemodynamic
• +/- Mechanical support
• CI to TPA
• Unstable Surgical embolectomy
• Stable embolectomy
• High risk for systemic TPA (bleed, plts, ICH, age, etc)
• Localized lysis
• Tailor therapy specific to patient

Conclusion

• Early recognition of RV failure as an etiology for patient deterioration
• Prompt implementation of medical & invasive strategies to treat RV failure
• Options for invasive mechanical options are available to off load RV
• Promote RV recovery and stabilize patients
• Mechanical circulatory support in PE patients complicated by acute refractory right

heart failure despite CDT.

• Low adverse events rates observed in small series
• Further study is warranted

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