So enlightening us about all different therapies for PE, I'm going to try to focus on PE shock and role of MCS devices. I don't have any disclosures. So why are we here? You know, pulmonary embolism in the space has come a long ways since the ECOS catheter was FDA approved in 2014, almost, so 10 years ago. However, if you look at the mortality from pulmonary embolism in the United States over the past 20 years, we have not made any difference. So these are data from the CDC National Death Index, and the pulmonary embolism mortality is unchanged. Why is that? So we don't know. So maybe the incidence is higher, that's why more people are dying, but it's also possible that patients who die from pulmonary embolism are the ones that are really sick, the ones in shock, the ones who are having cardiac arrest, and a lot of time and energy has been devoted to the lesser sick patients, the ones with intermediate risk. Pulmonary embolism, because we have been tied to this schematic that the Europeans taught us about looking at pulmonary embolism, so with low risk, intermediate risk, low, high, and then high risk. So our group recently proposed a different, more detailed schematic inspired by the Sky Shock Guidelines, which basically wants to think about pulmonary embolism in a more detailed fashion, using some hemodynamic and imaging parameters, and talking about the same five stages, stage A, stage B, stage C, D, and E. So not everybody with intermediate risk pulmonary embolism is the same, and not everybody with, so with a high risk pulmonary embolism in this, so it's the same as what Sripal mentioned about normotensive shock. So that patient is probably stage C, versus those who are not in normotensive shock is probably stage B. And the same thing with high risk, so you have the stage D patient that's deteriorating, but has not yet suffered the circulatory collapse or cardiac arrest just yet, and doesn't have a lactate super high. This used to be the dogma that with massive PE, you first make sure that they don't have a terminal illness, they are not, it's DNR and whatnot, but then if they suffer cardiac arrest, they're in shock, they're in respiratory failure, you go to thrombolytics, but if they are in these things, then you go to VA ECMO, plus minus surgical embolectomy to follow. However, this is probably the catastrophic pulmonary embolism patient that will most likely not do well no matter what, and so what about other MCS devices beyond VA ECMO, and how about thinking about percutaneous embolectomy options now that they exist? So these are the questions that exist right now. So what do we know about mechanical circulatory support to pulmonary embolism? I highlight this review by Dr. Atiran because it highlights the current state of data. You know, Sripal showed the eight patient randomized trial from 1994 in circulation that showed mortality benefit with streptokinase. In the MCS PE space, all you got, so all you have is these case series, and if you look at that chart, the most common number is one. So it's not even a case series, it's a case report. The data is largely restricted to four or five multiple patient case series, and if you look at the weaned from MCS rates down here, for the shock audience, this is not bad. You know, we're looking at 59%, 95%, 100%. The weaning time was about three to five days, so if done right, MCS may have a role in patients with acute pulmonary embolism shock. How do we do it? So before we go to MCS, we got to understand, not all clot is the same. Sripal hinted at this concept of, the clot in PE is mostly not acute and fresh. However, there is more to this chronicity, because what happens is you get the fibrin, and the fibrin over weeks to months can turn into elastin and collagen, and then you can have a mix. So you've got to look at the clinical picture. You've got to get your hemodynamic data, because if the patient has a mean PA pressure of 40, in fact, most randomized trials that are enrolling patients for thrombectomy versus swantic coagulation have an exclusion of PS systolic pressure of more than 70, because they don't want to enroll patients with chronic clot in those studies. And then you have to look at imaging, because imaging can not only help sort out the location of the clot, but also chronicity of the clot. If you look at these videos, this is acute PE. You can see the perfusion is still intact, but you see this large haziness in the center of the screen. However, if you look at these videos, you will see the lumen is intact. It's highly regular, but it's intact, but the perfusion is highly distorted. This is chronic disease. And then, so what you see here is acute on chronic. You can have both. And you've got to be able to figure out what's going on with your patient. So now, so coming back to MCS, it's largely for stage D and stage E, although stage E may be too far gone. How do I think about it if I were to put this whole thing together? So you have the VA ECMO option. The benefit of it is full support. You have an oxygenator, but it does come with the large-bore arterial access that you have to deal with. So you have the option of RA, PA bypass. You can do it with a protec. So duocannula, it gives you isolated RV support, but pretty good support. You can hook it up to an oxygenator. But the advantage is it comes, you can do it with just venous IJ access. And then you have the Impella RP, which is RV support, venous IJ access, but you don't get the oxygenator. So depending on the patient as to what's going on with them, you can pick one of these three. Then you have to figure out, is this acute PE that I'm dealing with? Is this acute and chronic PE I'm dealing with? Or is this just chronic PE from CTEP that you're dealing with RV decompensation? Because if it's acute PE, and you have to put somebody on MCS for it, so you don't want to just watch that patient, because a day on MCS is a day on MCS. So you want to move towards a thrombectomy, thrombus removal, a percutaneous thrombectomy option. You do not want to give thrombolysis to patients with large-bore arterial access, of course. Now if it's acute and chronic, the first goal should be to hemodynamically optimize them. That can be with diuretics, that can be with pressors, but then you also got to think about thrombus removal. And then if it's just chronic, you have to think about thromboendarterectomy and spulmonary angioplasty down the road as thrombus removal. So treat the shock first, take care of the clot next. If you're looking for resources, Sky was kind enough to give us a platform. There are several videos that talk through a lot of these concepts. There is a IC Clinics book. Thank you, and any questions? Thank you.

pulmonary embolism

mechanical circulatory support

PE shock treatment

ECOS catheter

clot classification