Specialists in vascular medicine, pulmonary medicine, emergency medicine, critical care, cardiothoracic surgery, interventional cardiology, and thoracic imaging in the new Acute Pulmonary Embolism (PE) Program at Brigham and Women’s Hospital (BWH) are collaborating to provide rapid assessment, triage, and management for patients presenting with signs and symptoms of acute pulmonary embolism.
“Pulmonary embolism is the third most common cause of cardiovascular death in the United States with at least 180,000 fatalities annually, and the incidence of PE appears to be rising,” said Mark Creager, MD, Co-director of the Acute PE Program.
The Acute PE Program provides patients presenting with suspected acute PE rapid assessment and systematic multidisciplinary care delivered through an integrated program, as well as coordination of multidisciplinary follow-up care after discharge. Patients who present to the Emergency Department (ED) at BWH undergo immediate evaluation by ED staff, who utilize a single pager to activate the Acute PE Program team if PE is detected. Transfers from an outside ED with detected PE or transfers with unstable or high-risk PE from outside hospitals are triaged to the BWH ED or directly to the Shapiro Cardiovascular Center, respectively.
“After an expedited multidisciplinary evaluation, we deliver advanced services tailored to the underlying condition and diagnosis,” said Aaron B. Waxman, MD, PhD, Co-director of the Acute PE Program and Medical Director of the CTEPH Program. “Many times, patients arrive to us with symptoms of acute pulmonary embolism that have not responded adequately to therapy and are ultimately found to have chronic thromboembolic pulmonary hypertension or another pulmonary condition. Our goal in establishing this Program is to assign patients to the most appropriate therapy as quickly as possible in order to improve outcomes.”
Treatment approaches used in patients with acute PE range from intensive anticoagulation, including the non-vitamin-K oral anticoagulants if appropriate, and systemic thrombolytic therapies to catheter-based low-dose thrombolysis and surgical embolectomy. Rapid assessment by the multidisciplinary team and state-of-the-art imaging are employed to choose the most appropriate therapy for each patient. In patients found to have chronic thromboembolic pulmonary hypertension (CTEPH), pulmonary thromboendarterectomy or balloon pulmonary artery angioplasty are performed in appropriate cases.
A 44-year-old female was transferred to Brigham and Women’s Hospital with a history of CTEPH and deep vein thrombosis (DVT). She presented with progressive shortness-of-breath and right heart failure. On admission, she underwent a comprehensive evaluation, including pulmonary angiography and echocardiography (Figure 1).
Findings were consistent with severe pulmonary arterial hypertension (PAH) with mPA 52 mm Hg and a PCWP of 6 mm Hg. The cardiac index was severely reduced at 1.94 l/min/m-2 and the PVR markedly elevated at 1092 dynes. Following inhaled nitric oxide, there was no reduction in PA pressure. Proximal thrombus in the right main artery was evident on preoperative PE-protocol CT (Figure 2). It appeared chronic. On full pulmonary angiography, there was clear cut off of the right middle lobe perfusion and early cut off and incomplete filling of the right upper lobe. Luminal defects involving the left upper lobe also were noted. These findings were consistent with CTEPH bilaterally.
After the team discussed and formulated short- and longerterm plans, targeted oral medical therapy with pulmonary vasodilaters was started for pulmonary arterial hypertension components of the patient’s CTEPH. She was counseled on surgery to improve symptoms and underwent a pulmonary thromboendarterectomy at BWH. At surgery, a large amount of thromboembolic material was removed from almost every branch of the right and left pulmonary arteries. Right ventricle function improved at the end of the procedure.
At three weeks after surgery, the patient’s shortness-of-breath had resolved. An echocardiogram (Figure 3) showed a less-dilated right ventricle, normalization of the interventricular septum, and resolution of the pericardial effusion. The estimated pulmonary artery systolic pressure had normalized.
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