sutures newsletter

PRODUCED BY AND FOR MEMBERS OF THE DEPARTMENT OF SURGERY May 2017 | Archived Issues

Cedars-Sinai Creates Pulmonary Embolism Team

By Oren Friedman, MD, Vic Tapson, MD, Danny Ramzy, MD, Aaron Weinberg, MD, Suhail Dohad, MD

We are pleased to announce the creation of the Cedars-Sinai Pulmonary Embolism Response Team. PERT is a multidisciplinary team including pulmonary, critical care, cardiology, interventional cardiology and cardiothoracic surgery that provides rapid triage and access to state-of-the-art care for intermediate and high-risk pulmonary embolism (PE).

Options for this deadly disease have increased exponentially in the past several years and include multiple endovascular procedures, cardiac surgery and extracorporeal membrane oxygenation (ECMO). These options are spread between multiple fields and in the absence of a PE team would require several phone calls to different consultants. The concern is that providers will be stuck in a maze of phone calls, which can delay treatment to a sick patient.

With the advent of our team, one phone call provides access to all necessary disciplines. Our members include:

  • Vic Tapson, MD, pulmonary critical care
  • Aaron Weinberg, MD, pulmonary critical care
  • Oren Friedman, MD, pulmonary critical care, cardiac surgery critical care
  • Suhail Dohad, MD, interventional cardiology
  • Danny Ramzy, MD, cardiothoracic surgery
  • David Hildebrandt, BSN, Heart Institute team manager

Providers can dial in to a dedicated phone line (3-CLOT) and will have 24-hour access to the team, including expert interpretation of CT angiography, VQ scan and echocardiography. The team will provide rapid clinical evaluation and triage of high-risk PE patients. The pulmonary critical care fellow or attending will field the call, gather information and begin to offer advice.

In certain scenarios — such as a massive PE (patients with hemodynamic instability) or a clot in transit — cardiac surgery will be involved immediately. The team will also help guide the often precarious decision to use systemic thrombolytics.

For intermediate risk, the team will provide an expert recommendation regarding indications for anticoagulation alone, IVC filter placement and endovascular treatment. Our cardiac surgeon, Ramzy, and our chief interventional cardiologist, Dohad, perform a vast array of endovascular therapy, including:

  • Catheter directed lysis, including ultrasound-assisted, catheter-directed lysis with the EKOS catheter
  • Clot extraction with the FLowTriever® device or the Angiovac® clot retrieval system
  • Surgical embolectomy or veno-arterial ECMO for patients in critical condition. (ECMO has been used at Cedars-Sinai to bridge patients to a variety of definitive treatments.)

In addition to inpatient treatment, our team can also arrange to monitor patients after they leave the hospital. Follow-up management for pulmonary embolism is crucial, as there are many nuances and options for long-term anticoagulation. The rise of direct oral anticoagulants has introduced many more options for long-term care, including low-dose extended anticoagulation.

Patients with abnormal RV function at the outset of their pulmonary embolus are at risk for long-term RV abnormalities and functional limitations. Our outpatient clinic is headed by Tapson, who in addition to having a national reputation in PE is an expert in pulmonary hypertension. The outpatient clinic can also assure the appropriate removal of IVC filters.

The Cedars-Sinai PERT team is a founding member of The National PERT Consortium headed by Massachusetts General Hospital. The PERT consortium hosts annual meetings to discuss leading-edge developments in PE care and provides a forum to collaborate on care and research.

Cedars-Sinai will contribute to the national database and will be able to publish from this database. The PERT consortium newsletter has featured Cedars-Sinai, highlighting our team approach and the availability of multiple modalities of advanced PE care — including our robust cardiac surgery and ECMO program — which have opened the door to aggressive PE treatment not routinely available at many large centers.

Numerous clinical trials and research projects are underway. A few highlights will follow. Data has been assembled on the multisite Optalyse PE trial led by Tapson, investigating numerous alteplase doses for catheter-directed thrombolysis.

Our center is also participating in a trial studying the FlowTriever® clot extraction device, and thrombolysis activatable inhibitor in acute PE. We are also studying portable VQ scans in the ICU, and will embark on a study of noninvasive cardiac output monitoring during acute PE.