Sunny Patel, we're going to talk about development justification of PERT. Some of these points that you guys all raised will be kind of covered through this. So I'm literally doing this right now because we keep redefining the PERT system. I think we've redefined it like 10 times in the last four years. But I just want you to get a background of what I'm coming from here. So 500 beds community, we give all the comprehensive stuff for cardiac care. We have comprehensive IR care and vascular care as well. To discuss why we should kind of get into this field, really it's because we are already providing peripheral arterial angio, peripheral venous angio intervention. We are already dealing with lead catheter thrombosis, and then clot in transit. And it's just the natural progression to keep going past that pulmonic valve to the PA. And the evolution is pretty clear. You all know this, but we keep following the same patterns of STEMI, acute limb, and stroke. I mean, we start with meds, then we do systemic lytics, and then we're doing catheter direct lytics, and now we're thrombectomizing. And the two things that keep coming up in all cardiology is go early and get LV, or in this case, RV support quickly if you need it. But these are the issues that we had to contend in the first three years of our PERT program. Clinical need, economics, stakeholders, management, dissemination, action, consistency, and collegiality. I'll try to go through each of these and kind of go through what we need. So we've already been through the epidemiology, so I won't keep harboring on this third leading cause of cardiovascular mortality, with 3% to 5% being hypotensive at presentation and still only getting anticoagulation or intravenous anticoagulation. And there are clearly inconsistent patterns of care between medical, interventional, and surgical specialties. And then there are semi-consistent risk stratification patterns for massive versus submassive versus low-risk, high-intermediate, low-risk, PESI scores, and then continuum versus definitive stages. And then all the concomitant issues that influence the above and dictate the various management strategies of bleeding, subarachnoid, shock, large bore, availability, et cetera. And the economic scope, as you guys already know, but when we talk to our hospitals, it's the average cost in our region, three-day length of stay, was $8,700. Obviously, it can be up to 10 days' length of stay, but with $250,000 in a year, with the average caseload per hospital for about 500 beds is about $150,000 to $250,000 a year. That's $2 million, not including the post-procedure follow-up morbidity and mortality costs—morbidity costs. It's a great paper in the Journal of the American Heart Association that kind of goes through—it's a European-based algorithm, but long story short, the type of PE, provoked versus unprovoked, and the issues related to cost basically keep compiling despite it being a single admission. You just keep accruing costs throughout the time of the patient's life. So when we talk about PERT, this is a very obvious definition that's been published many, many times, and it's been gone over by the panel, but the ability to rapidly assess and provide treatment for patients for QP, a formal mechanism, provide multidisciplinary approach, and then a feasible willingness to collect and share data for effectiveness of treatment. That fourth line is very important, and we'll talk about that in a second. But as you've seen this figure again, but these are the reasons you want a PERT team to justify to your administration what's going to make it—what's going to be the point of contention is the fact that who's providing that therapy. And when we do provide therapy, we have to stratify these patients and figure out what we're going to do. Because the risk stratifications are so random and there's so many, you have IR guys using one scoring, IC using another scoring, European guys using another scoring, vascular surgeon using another scoring, and everybody's making decisions based on different scores that they will put their heart into. Again, no randomized data to say one score is better than the other, but then who's managing the algorithm of how we're doing this in the hospital? Because that, unfortunately, causes a lot of confusion to your referrings and to people that are trying to send you a PE because they're trying to learn the same algorithms. The nitty-gritty of PERT economics are these things that we've dealt with. So the call rotation, ICU care, drugs and pharmacy on call, interventional equipment, ECMO, your imaging availability, CV, anesthesia, and CRNA availability for your cases. And the problem is the cost-effectiveness of PERT is based on physician volunteerism. And these are the two questions that people ask. And this has been asked over and over, am I on call for free and am I getting sued for advice? And you have to answer these questions because the answer is yes to both of them. And you've got to get people on board to say, hey, are you going to do this for free, sued for advice? And, oh, by the way, you're going to agree to thrombectomy, but I'm going to do it. And that is a very hard sell for any specialty, anywhere, anytime. And because you have these stakeholders, you have to kind of get everybody in line to say, is it worth it? I put us at the bottom because, unfortunately, we are. We started late and we're here now to try to do this. It's only five minutes. Okay. So, and you have to have these imaging services. So, unfortunately, we don't control the imaging services. It's not like EKG where I see the STEMI. It's like they've already seen it and they know and their partners know how to do it. And so you have to figure out how you're going to manage that scenario because we can have all the PERT discussions we want, but people have phone numbers and cell phones and texts that are happening behind the scenes that don't even activate. And we went through this over and over with, hey, you need to go through the appropriate channels. No, they don't. No one needs to. They never have. And it's hard to get people to be on the same page with you. And on top of that, you have this menu of catheters that everybody's good at, but not everybody's good at everything. And so you can't be the best at all different catheters. So now your PERT program is kind of in jeopardy of, hey, are we going to carry only three of these catheters because they're costing a ton of money and we're expiring them because we don't do this every day or because this guy didn't use it last week and now we have to use it this week? I mean, you get into this scenario with your administration about, hey, which ones are we going to have? And if IR and vascular want to use ECOS and we want to use Inari and AndroVac, which way is that going to go? And you have to keep coming to the table over and over to discuss this because of the expirations and staff training to the adjunctive equipment that you need to run your equipment. And then you get to the management. And unfortunately, the bad side of PERT is that you have to—it makes it hard for others. And what that means is you're complicating something that wasn't complex for a whole host of specialties. And you're saying that you're not the stalwart of systemic thrombolysis. You don't understand oral anticoagulation plus DAPT. You cannot deal with large-bore access because I do that every day. I'm the structural guy. It just doesn't work. It really—you can't force it that way. You have to kind of teach them. And that's what we did. We took this and said, let's go through it, guys. I'll teach you how to do anticoagulation. I'll discuss with you what we do with DAPT and Eloquus. I'll go through how to close a 26-front sheath and get out without bleeding. And if you need more help from the RV side, we're here because of biventricular failure shock and pellet. And don't close the hole. Let me exchange it out for you and I'll help you to get through that. Because you can't really get them on your team for this because they believe that they've been doing it longer, better, faster, smoother, had just as good outcomes as we did. We can write it in a paper and put p-values next to it, but they don't care. They just never have. And I'm dealing with a very experienced—and I like my IR guys. I really do. I love my girls. They're very good at what they do and I cannot fault them for it. But when they get into these scenarios, right, where the PA pressure is 20, I'm good. No, it's because you're not generating pressure. It's not working anymore. And they don't understand that concept. That's when we kind of got into the game, right? We're having RP impellas and protect duos and they're easily, rapidly deployable. We can use the same access points sometimes and not close one hole and put another hole just because they're going downhill. And they started seeing the value there. So I think one of the people asked, you know, they were self-selecting sicker cases. Unfortunately, that's what we have to do. That's what I had to do. I had to select the sickest cases, take them on, show value so that those easier cases would come from the outside hospital for us to evaluate and manage. And you get to this point where, okay, now we're not oxygenating, the RV's gone, there's no preload, the LV's gone, and we're in a serious scenario. Yes, can we deploy VA ECMO? Yes. Did they feel like we ever needed, that they were losing patients left and right, the entire field of vascular surgery, interventional radiology, because we didn't have VA ECMO? That is absolutely not what they believe. They don't believe that and they never will. We go to the meetings every month and they say, do we really need to have a team for this? We may deploy this, you know, a couple times a year, but it's still, for them, it's not something that justifies giving up their entire space of thrombectomy in the PE world. And so then you say, well, can I have a PERT team without an ECMO team? Yes, you can have a PERT team without an ECMO team. You definitely can. The numbers for ECMO and PERT are small. The benefit is about 30 to 50% of 100% mortality and biventricular shock. However, with the PERT partnership and the consortium, I mean, there's this suck and send policy that's going around, you know, where you suck it out and if you don't have an ECMO program, you send it to someone on some degree of hemodynamic support and you get protocols or advanced mechanical support to get them to these hospitals. Because you need perfusion, CTS, blood bank, ICU training, staff training. When are you going to get that transfer? Because once you put them on ECMO, it's a whole different game of who's accepting that patient now if you can't get further management. So once you get that and you disseminate, you need to figure out how to determine that the hospital, the outlying communities know your availability and then understand your ability. Because probably in any community hospital that you work at, anywhere within two to three hours, there's an academic center somewhere that can help out with the same situation and they can fly into that spot. So we had a paging system, I think. We had this activate PERT like STEMI and then we got rid of that because we were getting activated for every little PE there ever was and that was upsetting them. As interventionalists, we didn't care. We were up anyways, you know, getting STEMI calls left and right, but the radiologists could not stand it. I mean, they're not used to that. Vascular surgery could not stand it. They're not used to that either. So we had this pre-PERT activation thing that we developed where basically they call and they get a cardiologist or interventionalist or a CHF guy that's like an urgent consult any time of the day and they go over it and they say, hey, should we activate this system where we need to talk about thrombolysis, thrombectomy, et cetera. And we don't have a true PERT coordinator. I think a lot of programs have a true PERT coordinator if they have volume 200, 300 cases. We unfortunately threw this on our structural coordinator. So she kind of gets these PERT calls and then she calls and disseminates it to the other guys that say, hey, can you look at this and see what you want to do? But you're going to need one, you know, with the consortium and the registry and the accumulation of data in order to get some justification of what we're trying to do here. There's going to be this registry. You have to find the opportunities for improvement. So if they did one, I'm sure there's something you can do better on. If we did one, I'm sure there's something we can do better on. There's always ways to make it better. So we review it monthly. And then we market to the outlying hospitals, right? So that's the first thing that needs to go out is this exists to the outlying hospitals immediately before you start losing cases and the inability to build your program. But I think the biggest statement is who's going to lead that pack. And you have to have this one or two people that are willing to do this and kind of be at the forefront of organization and management. Some people want to rotate this. We had this issue where we wanted to rotate the leader of the pack. And you would notice if we did our data that that month, all the cases went to IR. And then the month I would flip in and all the cases would go to IC. And we just kept doing this swinging motion. And it just wasn't working. And then we went to weekly. Then we went to monthly. And now we have this dual leadership thing going on between two different people in an effort to try to get this collegially managed. And the problem with the expert in various interventions is, again, just that if IR takes the call, vascular surgery takes the call, and they're penumbra guys, but this really needs. But I'm an NRE guy and I'm using brands, but just so you're aware, large-bore versus intermediate-bore. Who's getting it? And who's going to do it? And then where are you going to do it? That's another issue that we contended with for many, many years. Where is this happening in the IR lab, the IC lab, the vascular lab, the hybrid lab? Where is it going to happen? Just because you're first, does it mean are you always going to be the first call? Probably not. But you're stuck trying to figure that out between different people. And when you do get called, what are you going to need to deploy the therapy versus what is they going to need to deploy the therapy? And you're not going to be able to justify changing the training of someone that's more veteran or someone that's equal in that scenario. And then finally, we keep talking about it as endovascular therapy. Remember, surgeons have been doing thrombectomies and thrombolectomies for years with Fogarty's and such. So you still need to involve them. They're still there. They still need to be a part of this scenario. Will they be activated as much as we or the percutaneous guys? Probably not. But when you need the OR, you're going to beg for them. And if you disclude them early, they don't really come when you need them. So can the management approach be standardized? I would say in five years, it can be. It took five years to kind of get everybody down the same catheter, same management protocols, et cetera. But the dictation of care and the care equivalency, you need to work through that early because that will really change who's referring and why they're referring to you. You know, if the hospitalists think that this is the way you're supposed to do it and the algorithm is different from vascular, IC, IR, it really doesn't work. Most of these people actually want to know your algorithm. They're very open about it. And they want to understand how do you do it so that they don't look dumb because they want to look very knowledgeable in this scenario. But if you guys change the algorithm based on the operator, this, we found, failed. And we had to go back to the table over and over to try to figure this out. And again, will the stakeholder agree when they're not proceduralists? Unfortunately, this is a time of economics. And this is a situation where you're taking my pie and I want to eat it too. And no matter how good we are for patients and what we want to do for patients, this will still always be in the background dictating care. And so if I'm the guy getting the throne back to me, but they're the guy getting the call, that has to be equal. You got to do the vice versa too. You got to feel, you're going to feel the pain, I promise you, as an IC that can hold a catheter when you have to say, go ahead and you do it. When you could do it, you're available. You're sitting there writing a clinic note. You're going to feel it, but you have to do it. Because if you don't do it, this can't work. You have to give and take similarly. And then can prevent the above issues? That's the problem. The data is there. And can we make everybody do everything? Yes. But do they want to? And if you force someone to do something, it pretty much never works. I'll show you one we just did a couple months ago. So here's 53, depressed, alcohol. She's got blood alcohol negative. She's got all the symptoms. Her PESI score is 123 and we activate all these people. The ED gets it. The hospitalist admitted it. The proceduralist is called. The CT, the echo, the ICU. You got all these people running around the hospital for one patient and no idea what's going on. Should we go suck it out? Should we do thrombolysis? What should we do? So long story short, it ends up coming to us through a cardiologist, through a hospitalist, etc. And we basically score it real quick, okay? We have the most basic scoring system ever. Low, intermediate, high, based on these things. This Geary article is excellent. We look at the other factors that say, hey, can I do a thrombectomy, can I do thrombolysis? We go down the algorithm from the EHJ, which is very easy to use. This is pretty much the easiest algorithm that I could come up with for outlying hospitals that would combine all the data that I know. It's high risk. We go in. We have the CT. We have the RV, LV. We have the McConnell sign. We go in. We suck it out. She's still in an RV failure. You can see from the SWAN. She's still in the RV impella. She goes on four days later. So it works. It's great. It's easy. It looks easy, but it took five years to just show you four slides because that's what it takes. But the bottom line is that it's not done after PERT, and that was the selling point that we had, that you need to have CHF, heme, and all the other specialties available to make this a reality, that PE is not done at the discharge. And that's sort of another point that you have to keep in mind when you're selling this to your administration. PE is not done at discharge. Anyways, PERT is the way of the future for us, I think. The costs of PERT are real, but you can do it. It just needs consistent team-based care. You should educate and disseminate as soon as you guys are established. Thanks. Thank you so much. So we're going to be moving pretty quickly into the next session, so we'll get Dr. Klein up. As we do, you know, it's important to say out loud, this figure gets kicked out about less than 4% of PEs get treated interventionally. And though we don't want to treat 100% of them, the number of intermediate, intermediate to high risk is probably closer to 20% to 30%, and it's these factors that are going to change that. It's about how these teams grow. It's about the fact that not every team needs to be a multidisciplinary phone call. It's about different paths towards getting this done. As we start to transition to the next session, any thoughts, anything we missed? We heard some consistent themes, you know, mobilize your frontline providers, create ways of doing your outreach, work with your collaborators in a way that's practical. Any other thoughts? And Drew, I'll include you in this. Anything we missed? I think if you've seen one PERC team, you've seen one PERC team, and that's it. It's going to work differently at every institution. So do the best you can at your institution, understanding that the politics are all different and it may look totally different for your place and my place, it doesn't matter as long as we get the job done. I think that, you know, regardless, especially, I think the focus on hemodynamics is key. I think that's what really distinguishes our field is the understanding of the RV. And I think when you sort of frame it in that discussion, I mean, I tell my fellows every single, when they start, I don't really care about the clock pictures. Tell me about the PA pressure and the cardiac index. And I think when you start framing in what the RV is doing, and like Dr. Patel so eloquently said earlier, I think that is really what distinguishes our field and why we need to be in this space. You know, one thing I'll say out loud, though, not everyone wants to be on phone calls at 3am. And I think that's what people appreciate when you do the outreach before a phone call at 3am. So, you know, be the part of the team that calls your cardiac surgeon and says, hey, what are your thoughts on ECMO and PE? You know, call those hematologists and say, hey, would you be the person that would want to see a thousand PE patients and follow up for hypercoagulable evaluation? You know, find those people and they're going to then start feeding back into the system. We put the director of our ER as a co-investigator on HyPytho when we started it. We added them to the PERT team knowing they weren't going to have to do anything besides look at our volumes and procedures afterwards. And it started driving a lot of that stuff into us.

PERT

development justification

Pulmonary Embolism Response Team

multidisciplinary collaboration

patient outcomes