A cutting-edge treatment for pulmonary embolism (PE) is giving medical personnel a new weapon in the treatment of these deadly lung clots. Physicians at Princeton Baptist Medical Center are leading the way with the state's first comprehensive PE response team which uses cutting-edge, minimally invasive techniques to treat even the largest clots. The new treatment techniques often avoid the need for high doses of clot-bursting medicines or open heart surgery.
A major cause of morbidity and mortality, PE is both common and dangerous and affects almost one million people each year in the United States. "PE may often present as sudden death. For those who survive, there is the possibility of decreased life expectancy and impaired quality of life. It is critical to make sure cases are diagnosed correctly and managed properly as that can make all the difference," says Mustafa Ahmed, MD, director of the PE response team, and one of the team's interventional cardiologists.
PE typically begins with deep venous thrombosis of the leg that moves through the right side of the heart to the lung and blocks blood flow. "When I am informed about a PE, the first call I make is to Mike Crain, MD, the team's pulmonologist," Ahmed says. "We assess every patient together and decide on the treatment required. It's not uncommon for us to have a cardiologist, pulmonologist, radiologist, cardiac surgeon, and anesthesiologist and emergency medicine physician all making decisions and treating the patient together, even in the early hours of the morning. It's an incredible and very unique team effort."
Determining the immediate seriousness of a large PE comes down to two main factors: the stability of the patient and the strain placed on the right side of the heart. "Based on these factors, we characterize the PE as submassive or massive," Crain says. "Massive PE's are extremely high-risk events and a serious situation that often results in sudden cardiac arrest. Submassive embolisms are not as dangerous but can still be considered high risk for a poor outcome. It is important to note that not everyone with a submassive pulmonary embolism requires aggressive procedures, although it is important to identify those that are at the highest risk and treat them appropriately."
While there are several treatment options for PE, the therapy chosen depends on what is available at the facility. "The key is to have a team of specialists and every treatment option immediately available, whether it is just blood thinner or emergency surgery," Ahmed says. "A treatment we commonly use for large PEs involves specially designed, tiny tubes known as EKOS catheters. We insert the catheter through the leg and into the arteries of the lung where we use ultrasound waves to pulse tiny doses of clot bursting medicine directly in to the clot, often dissolving it in a matter of hours. It is incredible technology. In the case of massive PEs, my preferred technique is to use different instruments to break up the clot before potentially using the clot bursting medicines."
Treatment of PE is a rapidly evolving field, particularly when it comes to catheter-based therapies. "We noted that concomitant use of intrapulmonary thrombolysis with other catheter-directed treatments had a significant interaction and led to decreased in-hospital mortality. This may be because index catheter-directed treatment exposes a larger surface area of thrombus than what would ordinarily be exposed to intrapulmonary thrombolytics," Ahmed says. "The favorable efficacy outcomes can likely be explained by the fact that the catheter-directed treatment allows for a targeted method of relieving obstruction, which leads to restoration of blood flow through pulmonary arteries and reduction of right heart strain."
Ahmed is the senior author of two recently published studies that have examined the role of catheter-based techniques and surgical treatments for large pulmonary embolisms. The research group includes first authors Navkaranbir Bajaj, MD of Harvard Medical School and Rajat Kalra, MD, of the University of Minnesota.
PE team members include:
Interventional Cardiology - Mustafa Ahmed, MD (Princeton) and Hudson Segrest, MD (Shelby)
Pulmonary medicine - Mike Crain, MD
Team coordinator - Brad Richardson
Cath Lab team - Katie Evatt; Brooke Harris; Bobby Wells
Intensive Care - Josh Smith, MD and Ronnie Roan, MD
Cardiovascular Surgery - Clifton Lewis, MD
Emergency Department - Bruce Burns
Mustafa Ahmed, MD, Princeton Baptist Medical Center