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This podcast is developed by the Pulmonary Embolism Response Team (PERT).  PERT Consortium was developed after the initial efforts of a team of physicians at Massachusetts General Hospital. The first PERT sought to coordinate and expedite the treatment of pulmonary embolus with a balanced team of physicians from a variety of specialties.  Listen here for the lastest in research and discussion on Pulmonary Embolism.

Dec 19, 2019

Episode 4: Dr. Rosenfield interviews Dr. Richard Channick on Post PE care!

Dr Channick is the current PERT Consortium president and is the Director of the Acute and Chronic Thromboembolic Disease Program within the David Geffen School of Medicine at UCLA. 

Dr. Rosenfield is Section Head of Vascular Medicine and Intervention at Mass General Hospital and past PERT president and founder.


What happens after a PE?

  • Following acute pulmonary embolism some patients do not return to their baseline and may suffer from what is called post PE syndrome.
  • Some of these unfortunate patients develop chronic thromboembolic disease or chronic thromboembolic pulmonary hypertension

Follow Up Clinic

  • In clinic it's important to assess if patients have returned to their baseline of physical acitivity. If the answer is no, then go for objective testing
  • First step may be getting a follow-up echocardiogram or repeat imaging
  • CTA is extremely helpful for acute pulmonary embolism. CTA is less revealing for chronic pulmonary embolism. VQ scan is the most sensitive test for the chronic pulmonary embolism.  If VQ scan is normal 8 to 10 weeks following acute PE rhythm you do not have any chronic pulmonary embolism
  • Following an abnormal VQ scan next steps should be --> evaluated for CTED or CTEPH.

Define chronic thromboembolic pulmonary hypertension and its characteristics?

  • CTED or CTEPH is a scar tissue forming in pulmonary vessels is not an acute clot. à higher degree of such vascular obstruction will lead to increase in PVR and eventually PHTN and RV dysfunction.
  • CTED or CTEPH has distinct appearance on imaging: Chronic clot may have appearance of fibrous bands, webs or bands. Appearance is quite different than acute clot.
  • Extremely high pulmonary artery pressure of about 80 or 90 millimeters of Hg suggest chronic right ventricular pressure overload.
  • Bronchial collaterals on CTA may suggest a chronic process.

Acute Vs Chronic Clot on Imaging:

  • Acute clot will have a central occlusive appearance.
  • Sometimes it is hard to differentiate. If patient has not been anticoagulated in the past you anticoagulate and do a follow-up in 8 to 10 weeks.
  • Signs of RV hypertrophy on the echocardiogram also suggests a chronic process

 

Treatment of chronic thromboembolic pulmonary hypertension

  • First-line of treatment is surgical. [It is complicated cardiac surgery that involves expert surgical team. It involves cardiopulmonary bypass, deep hypothermic arrest and needs and expertise.]
  • Balloon pulmonary angioplasty growing evidence.
  • RIOCIGUAT is the only approved drug for CTEPH. Macitentan has been studied but not approved. PDE inhibitors   also have been tried
  • Upfront medical therapy should not delay the referral for the patients who potentially are surgical candidates.

Types of chronic thromboembolic pulmonary disease  and surgical classification

  • Four levels depend on whether the disease starts
  • If the disease starts proximally it is easier for the surgeon to dissect. It depends where the chronic clots are involving the pulmonary vasculature.

Level 1 disease: Proximal disease
Level 2 disease: Lobar disease
Level 3 disease segmental disease
Level 4 disease sub-segmental disease

Basics Concepts of Balloon Pulmonary Angioplasty (BPA)

  • It involves dilating the narrowed pulmonary segments and improve with the primary pulmonary perfusion and reducing the pulmonary hypertension.
  • First step is to do the pulmonary angiogram. Then match the perfusion defects with the VQ scan.  Work as a team.
  • Goal is not to over distend the pulmonary vasculature. Goal is just to break up the scar or the fibrous tissue and increase distal perfusion. Vascular stenting is not performed usually.
  • BPA is a staged procedure. The session can last anywhere between 2-3 to 12-13 sessions.
  • Each session is 2 to 3 hours involves fair amount of radiation and the contrast.
  • Pulmonary hemorrhage is a very serious complication; BPA has a learning curve.