Well, thank you very much for inviting me, and this is a great session where we really get to dive deep into pulmonary embolism, so I have 10 minutes to tell you that PERTs matter and our day is worthwhile, so I'm going to try to do that. And so, the goals of PERT, as you've heard—and this goes back to the first paper in 2013 that was published—is to advance the diagnosis, treatment, and outcomes of patients with severe PE and do so leveraging both a rapid response concept as well as a multidisciplinary team-based approach. And the reason for this is that there is a gap in VTE treatment. We know that this is a disease that traditionally has not been owned by any one specialty, and there's been multiple caretakers or physicians that are involved in this field. And because of that, less than 5% of the patients with PE receive advanced therapy, and obviously many more are probably eligible. The reason for this is system failures—you know, sometimes the data is not integrated in real time—lack of coordination or inability to respond rapidly, clinician barriers, fears of complications, decision-making or paralysis, lack of expertise or knowledge of the newer treatment options or paradigms, and then it's a heterogeneous disease presentation. We often make analogies to other cardiovascular diseases like MI or stroke, but the truth is that this is a different disease process. The venous bed is different, the way pulmonary embolism behaves is different, and often these patients can present on quite a broad spectrum of very low risk to very high risk, and that can sometimes present a challenge. And so when you take all of this and now you have these brilliant diagrams that my fellows have put together about all the different options and risk stratification and all that, integrating all of that can be quite tough. And then on top of that, you layer our device partners and all the amazing technologies that they are bringing forward, and again, you can understand why there would be quite a bit of room for streamlining the process and for having discussions amongst experts about what is the best thing to do for these patients. So the idea is to interface across discipline. PIRTs can differ, vary based on the institutions. This was an article from Greg Barnes's group about—Jeffrey Barnes's group, I apologize—looking at the different composition of PIRTs, and so you can see that depending upon the institution, you may have different specialties involved, and that's okay. The idea is to get those people who have an interest, an expertise, and really want to dive deep and understand this disease process, how to take care of these patients, getting on the same page, and making the best decision for these patients in a rapid, real-time fashion. The ESC has taken note of this, and this is now guideline-recommended. So this is a class 2A but level of evidence C in the ESC guidelines from 2019 that a multidisciplinary PIRT team would be helpful. So what do PIRTs actually accomplish? The data is still evolving, but we do have quite a few articles that are now in the literature. When I did my usual PubMed review, when I was preparing a talk, there was over 140 articles now on PIRT, and I think if you consider that the first article was in 2013, in 10 years, that's a tremendous amount. Most of those are in the last 2 to 3 years, to be honest with you. So we know that PIRTs drive consults. On the left is data from the MGH, and they broke it down by 6-month intervals, and you can see that there was a steady increase in the number of consults once a PIRT team was active. On the right is our data from New York, and this was during the COVID pandemic, and you can see by having a multidisciplinary PIRT team, when you have an influx of patients with thrombotic complications, it certainly drove us being called. We know that PIRTs drive advanced therapies. This is also from the MGH, and you can see that on the left is a pre-PIRT era, on the right is a post-PIRT era, and you can see that while TPA usage was relatively equal, catheter-directed therapy was much higher, and any advanced treatment was much higher. That's pretty consistent across the board, that there are more advanced therapies being offered. Now, the next question is, okay, well, that's great, so we're utilizing teams and we're doing procedures, but are we making a difference to the actual patient? So across different studies, PIRTs tend to reduce length of stay. This is data from Minnesota, and you can see that baseline is on the left. They instituted a treatment algorithm in the middle and then a PIRT on the right, and you can see that once they had a treatment algorithm and a PIRT in place, their length of stay was cut nearly in half for these patients. Our internal data—this is unpublished—also showed that for ICU patients, our length of stay was reduced by up to 40 to 50 percent. So it was 12 days if you had a PIRT consult, you were in the ICU. If you did not get a PIRT consult, this was over the same year, and this was 2019, pre-pandemic. We found that the length of stay was much longer if you did not get a PIRT consult, and what we found is that when you took the overall cohort, the length of stay was the same, but that the PIRT consultations were sicker patients. So it sort of suggests that by making these decisions rapidly, we are able to move them through the hospital system sooner, which may be something that you can bring up to your administrators when you justify why a PIRT team is useful. And this is new data from Iran. So even outside the U.S., you can see here that they had no difference in death, no difference in complication, no difference really in hospital duration, the small numbers, but the time to decision was much lower once you had a PIRT. So this does suggest that PIRTs are successful, at least at different implementations of making decisions rapidly and therefore taking care of these patients in a more expeditious fashion. But now you're all going to ask me, okay, that's great, but are you doing anything clinically relevant towards the patient? So does PIRT affect mortality? This is data from our center. This is the pre-PIRT era, which is about 2012 to 2014. The PIRT started in 2015, and so 2015 to about 2017 or so. And we did find a quote-unquote trend, so it was not statistically significant, I believe, because of small numbers, but bleeding risk was actually lower. And this is, remember, pre-thrombectomy. This is all ECOS era. And then when you sort of see newer data, UVA did see a signal towards a decrease in mortality, so on the top of the graph there in the red is the PIRT era and the bottom is the pre-PIRT era, and that's patient survival. So you can see survival is better in the PIRT era. And they had some sicker patients in the PIRT era. This is data from Cleveland, from New York City Hospital's case, and what they did was an interesting thing where they matched patients during the same time period with PIRT patients and no PIRT patients who were of a sufficient risk profile. What they found, that mortality was better, or it was actually zero in the PIRT group at 30 and 90 days versus the no PIRT group, and that readmissions were also lower, similar rates of bleeding. Now, again, all of this data is retrospective and therefore subject to the bias and confounders that do exist in that kind of data, but it does provide some interesting signals. And then this is also from Cleveland, but from the Cleveland Clinic, and again, they also saw that in the pre-PIRT era versus the post-PIRT era, there was a difference in mortality, and that post-PIRT era had lower mortality versus the pre-PIRT era. There's been two meta-analyses that have now been published looking at this, and you can…it's a little bit small to see, but you can see on the left, their advanced therapy was higher when the aggregated studies were published in the literature. Bleeding was about the same, and mortality was not quite reaching statistical significance, but certainly looked like there may be a favorite there. And then this is from Dr. Constantinidis, and this was the most comprehensive meta-analysis. They looked at 26 studies, 9,000 patients with PE, 9 studies with pre-PIRT as a control arm, about 75 percent at intermediate-risk PE, 16 percent with high-risk PE, and they only found 30 percent of patients with PE are evaluated by a PIRT, and I think that can vary across different institutions, certainly. They found that around 6 specialties were involved in each PIRT, that there was at least a cardiologist and a surgeon in every PIRT, and that mortality was no different, but in the higher-risk PE was trending towards significance. Length of hospital stay was better, and use of advanced therapies was higher. So, in summary, do PIRTs increase utilization of advanced therapies? The answer to that is likely. Do PIRTs decrease length of stay? The answer to that is probably. And do PIRTs decrease mortality? The answer to that is possibly.

Pulmonary Embolism Response Teams

diagnosis

treatment

outcomes

multidisciplinary team-based approach