Submassive PE: When do you stop therapy? Andrew J. P. Klein, MD, - - PowerPoint PPT Presentation

Andrew J. P. Klein, MD, FACC, FSCAI Interventional Cardiology Vascular and Endovascular Medicine Piedmont Heart Institute Atlanta, GA

Massive and Submassive PE: When do you stop therapy?

Disclosures:

▪ I have nothing to disclose.

• None
• Not a talk about what therapy is best

Conflict of Interest

• What are we trying to prevent?
• Death
• CTED
• CTEPH
• Post-PE syndrome

– Limited functional capacity

• When do you stop?

– Surgery→Obvious – Lytics→ Obvious – Catheter-directed therapy→???

Therapy Endpoints

How did your patient present?

• 1. Hypotension

– Remember its relative

• 2. Hypoxemia
• 3. RV dysfunction
• 4. Tachycardia

Should we follow symptoms? Should we follow biomarkers? Should we repeat the CTA? Follow the PA pressures? Serial Echos? Telemetry? Eyeball test?

Endpoint of Therapy

• Massive:

– Acute PE with sustained hypotension (systolic blood pressure 90 mm

Hg for at least 15 minutes or requiring inotropic support, not due to a cause other than PE, such as arrhythmia,hypovolemia, sepsis, or left ventricular [LV] dysfunction)pulselessness, or

persistent profound bradycardia (heart rate 40 bpm + shock)

PE Categories

• Goals

– Stabilize BP – Stabilize hypoxemia

• Options +/- ECMO

– Surgery→Obvious – Lytics→Obvious,maybe

–CDT→???

• Once patient

stabilizes then …?

Massive PE

Massive PE-Surgery

Therapy ends at end of case

• Systemic Thrombolytics

– Alteplase, tenecteplase – Ease of Administration – ICH Risk – Usually reserved for massive PE

• Done once drug is pushed

– Watch and wait

Treatment of Massive PE: Lytics

• ACP recommends CDT in

massive PE:

– Contraindications or failed thrombolysis

• 1 large CDT study

– 594 patients – 86.5% clinical success

• Stabilization of

hemodynamics, resolution of hypoxia, and survival to hospital discharge

• But how much TPA and how

long for other endpoints?

Treatment of Massive PE-CDT

Kearon C, Akl EA, Ornelas J, et al. Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report. Chest 2016;149(2):315–352. Kuo W J Vasc Interv Radiol 2009;20(11):1431–1440.

• Acute PE without systemic hypotension (systolic blood pressure 90

mm Hg) but with either RV dysfunction or myocardial necrosis – RV dysfunction:

• RV dilation (apical 4-chamber RV diameter divided by
• LV diameter 0.9) or RV systolic dysfunction on echocardiography
• RV dilation (4-chamber RV diameter divided by LV diameter 0.9) on CT
• Elevation of BNP (90 pg/mL)
• Elevation of N-terminal pro-BNP (500 pg/mL); or
• Electrocardiographic changes (new complete or incomplete right bundle-

branch block, anteroseptal ST elevation or depression, or anteroseptal T- wave inversion)

– Myocardial necrosis is defined:

• Elevation of troponin I (0.4 ng/mL) or
• Elevation of troponin T (0.1 ng/mL)

Submassive PE

Jaff M et al. Circulation. 2011;123:1788-1830.)

Predictor of 30d mortality

PESI and sPESI Scores

Jiménez D et al. Arch Intern Med 2010;170(15):1383–1389.

Unhappy Right Ventricles

Marker Risk Increase in Mortality RV/LV ratio >0.9 on CT 2.8-7.4X RV Dysfunction on echo 2.4X Elevated Troponin 4-8X Elevated BNP 6x

• Therapies

–Anticoagulation alone→ once on meds? –½ to full dose lytics→

• bvious maybe

–Surgery→ obvious –CDT→ ???

• What are we treating?

Submassive PE: When to stop?

Treatment of Submassive PE-Lytics

Therapy Endpoint=Drug pushed

• Local Delivery of Lytics
• Most often done with

Pigtail worldwide

• +/-PA angiography
• Adjunctive therapies can

also be performed simultaneously

• Pa pressure
• 10-20 mg of rTPA per

lung over 12-24hrs

Treatment of PE: Catheter-Directed Therapy

J Vasc Interv Radiol 2009;20(11):1431–1440.

Treatment of PE-Aspiration

Treatment of PE: Aspiration Thrombectomy

Treatment of PE-Remove it

Treatment of PE: INARI

After Before

• PERFECT registry

– Global prospective registry of CDT – >100 massive and submassive PE patients – > 80% clinical success rate – No major bleeds – Significant reductions in pulmonary arterial pressure.

• Should we follow this?

– NO ENDPOINT DEFINED

Treatment of Submassive PE-CDT

Chest 2015;148(3):667–673.

Treatment of PE: CDT Trials

ULTIMATE TRIAL

• 59 patients w acute main or LL PE + echo RV/LV ratio>1.0 randomized to UFH +

USAT regimen of 10-20 mg TPA over 15 hours vs. UFH alone

• @90 days repeat echo:

Majority of patients had no or mild right ventricular dysfunction EKOS group however had complete recovery (100% versus 93% UFH group, P=0.003) Important clinical correlates (such as exertional dyspnea) were not reported. Seattle II Trial

• Prospective, single-arm 150 pts receiving EKOS
• THERAPY ENDPOINT: 24 mg of t-PA administered
• 25% reduction in RV/LV, 30% decrease in PASP, 30% decrease in clot burden

OPTALYSE

• Circulation. 2014;129:479-486.)

J Am Coll Cardiol Intv 2015;8:1382–92

• Systemic Lytics

– TOPCOAT study

• Lytic recipients @3 months

– Normal RV function – Exercise capacity – Perception of physical wellness – CTED (?%) vs. CTEPH (2-4%)

• CDT
• What does and how long 6 mg, 10 mg? 20 mg?
• When do you stop?

Long-Term PE Outcomes

Resolution of PE with Heparin alone

– Negligible after 2 hours – ~10% after 24 hours – 40% after 7 days – 50% after 2 to 4 weeks

When do you stop?

• Resolution of PE with

thrombolytics

• 10% at 2 hours
• 30% at 24 hours
• 45% at 7 days
• 50% at 2 to 4 weeks) but

does not alter the extent of residual thrombosis

Kearon, C. (2003). Duration of therapy for acute venous thromboembolism. Clinics in Chest Medicine. http://doi.org/10.1016/S0272-5231(02)00076-X.

• Therapy ends with

– Surgery→ Obvious – Lytic→ Obvious – CDT

• Alive
• No bleeding
• BP stable
• Hypoxia resolved
• Heart rate
• RV function-echo
• CT, maybe but radiation
• Eyeball, Symptoms
• PERT TEAM DECISION

Conclusion

Thank you!