Good morning, I actually just recently graduated from Penn and I'm a first year attending at Northwell and I'm excited to be here this morning. I have dealt with working with a lot of different stuff, especially as we start a program at Northwell, so it's very close to my heart talking about how important it is to be able to get along with other people, despite having strong personalities for the better care of the patient. So, Dr. Sethi is going to go over a lot of epidemiology, but in general, PEs are common. They're a leading cause of cardiovascular death. A lot of them go silently, and there's still significant treatment gaps in PE management. I'm going to go through some complex cases to give you an example of cases. I think it's not just one person making a decision, but multiple specialties across disciplines. The 69 year old with a history of hypertension, hyperlipidemia, hypothyroidism, had pneumothorax, interstitial lung disease, had a recent single lung transplant. Two weeks ago, presented with new shortness of breath, found to have a right main and segmental PE and a lower extremity proximal DVT, intermediate high risk PE. A 33 year old with a past history of COVID pneumonia, family history of VTE, had an orthopedic fracture, had reduction in casting, and then recently gave birth with an uncomplicated delivery, presented with acute shortness of breath, and so on, have bilateral main and segmental PEs. And then a 45 year old with a history of adenomyosis, had a myomectomy, has a large fibroid, has ongoing vaginal bleeding related to her fibroid, a cavernous sinus thrombosis, has had multiple prior lower extremity DVTs and PEs, has gotten cathodectomy, mechanical thrombectomy, presented with syncope, had a high risk PE. But at this point, the fibroid had gotten so big, it occluded the IVC and biloiliac veins. So all of these cases required different sub-specialists to try to figure out what the best thing to do for the patient is, both in the acute setting but also long-term in terms of morbidity and mortality. So PERT is a team sport. As you know, multiple specialties are involved, whether it's cardiology, interventional cardiology, or vascular medicine folks, pulmonary, critical care, or cardiothoracic surgeons, hematology, and in some places where interventional radiology and vascular surgery actually take care of the PEs. And then case-specific with some of these surgical sub-specialties like neurosurgery in our spinal patients or in any of our high-risk OB patients, MFM. And I think the key to this is you have to engage true partners in this team-based approach, both on the medical and the surgical component. You have to find people who are really engaged in taking care of PE and want to move the field forward and also have your back when you need help. It's a lot of work to be on call 24-7 trying to build this, and you want to have people that you can trust and can actually offer you the support that you need. I think it's important to understand that you can't do this by yourself. You need help, and it's important to remain humble and modest and accept other opinions and be willing to do something for the better of the patient. So what are the goals of PERT? To facilitate multidisciplinary discussion about a patient as well as contribute to evolving PE management in terms of evidence in clinical trials. The real goal of PERT is to reach a consensus and then move forward with that plan once everyone's in agreement. And again, patient-centered care, so the patient should be at the center of that decision. And it's not just inpatient, it's also outpatient. So ongoing surveillance imaging, hypercoagulable workup, malignancy workup, figuring out duration of anticoagulation, whether you can reduce dose. But I think it involves all care of the patient. So I'm going to go through some of the data that looks at the beginning of PERT teams and how they're made up differently. So this was just a survey done at a PERT consortium registry that demonstrated there's a lot of diversity in the different PERT teams, but also the patients that require PERT discussion. To the left is a demonstration of what subspecialties and the providers are asked that made up their PERT teams. And then onto the right is an example of where these PERT patients were when they were admitted to the hospital in terms of the teams taking care of the patient. It's been shown in single institution studies that the impact of PERT actually affects the care in the emergency department. So this was a study that looked at what happened in the ED with initiation of PERT. And what they show was there was a decrease in time from patient triage to PE diagnosis, a reduction in times in terms of initiation of anticoagulation, as well as a reduction in time from triage to patient admission, all optimizing patient care with patients with PE. In addition to clinical care, it's also been shown that PERT is beneficial to both your medicine residents as well as your fellow education and training. It also provides comfort as well to faculty not as well involved in PE care. And then this is another survey that was done at one of the PERT consortium meetings that asked experts in the field in PERT about how they might manage PE in different clinical vignettes. In general, there was overall agreement of how we risk stratified patients. But as you can see, there was substantial variability in the treatment strategies of patients who presented with commonly encountered clinical scenarios. So we're going to go through some single institutions in terms of how PERT affected their ability to manage PEs and outcomes in patients. So this is a study from Cleveland Clinic. And what they demonstrated is with initiation of a PERT team, there was a reduction in 30-day mortality. There was shorter time to begin therapeutic anticoagulation and get therapeutic. There was also a reduction in major bleeding. This is a study from the University of Rochester. What they demonstrated is that with PERT, there was a sustained reduction in mortality at six months, greater than the three months shown before. And it's the only study that's been shown to have a sustained reduction in mortality. What they also demonstrated was that the time to triage the diagnosis of PE was independently predictive of mortality. And as compared to other studies, also that it led to reduced length of hospital stay. This is also from the University of Rochester. And what they demonstrated is that after initiation of PERT, more patients were getting advanced therapies. Whether that was related to more patients being discussed in a multidisciplinary fashion, and as to discussing what treatment therapies were available, but also I think education across the team about what each subspecialty can contribute to taking care of PEs. This is from the University of Kentucky. And what they demonstrated was that PERT, similar to other institutions, expedited treatment and reduced variation of care and reduced ICU stay as well as length of hospital stay. And there was no impact on direct cost. And there was—in this study, there was no significant difference in mortality rate. So kind of putting all this together, this is a recent meta-analysis looking at the PERT teams. And what you can see is that, in general, with PERT implementation, there was a greater use of advanced therapies and a shorter in-hospital stay. In this meta-analysis, they were not able to show a significant survival benefit in patients with PE once PERT was implemented. And I think this meta-analysis is strongly suggesting that we need large prospective studies to further explore the impact of PERT on clinical outcomes. So what about the sickest patients with the highest mortality? So this is a study that looked at, was there a role for advanced therapies in our really sick PE patients? So this is an analysis of a prospective database of patients with both massive and submassive PE. And what they found after multivariable adjustment was that massive PE was associated with a greater than 5-fold greater hazard of mortality. And with advanced therapies in these patients with PE, there was a 61% reduction in mortality. This is another retrospective chart review that looked at, was there a role for ECMO in these sick patients in terms of morbidity and mortality? And what they compared is patients with massive PE before and post-ECMO kind of era. And what they demonstrated was that there was an increase in 30-day survival in patients who were able to get ECMO in terms of treatment for helping manage the hemodynamics with PE. And I think what this demonstrates is that PERT is going to be very important in terms of facilitating these multidisciplinary conversations about are the patients a candidate for mechanical support? And are there more advanced therapies we can offer this patient? I think it's a way to streamline these patients, especially with our trials coming up with our high-risk PE patients with flame and upcoming data. I think it's going to be very important that these discussions are multidisciplinary. So in summary, so PE care is continuing to evolve, and I think we as interventional cardiologists have procedural skills and clinical knowledge to be leaders in this space based on our understanding of the hemodynamics, but also our catheter skills to take care of these things. I think coordinating an institutional approach to complex life-threatening problems works with multiple specialties to provide optimal patient-centered care. I think PERT is a model program to have interdisciplinary collaboration to streamline care, optimize outcomes, and establish evidence-based and develop better treatment paradigms. And I think the PERT Consortium is going to be a great way for us to continue to do this, building a registry to provide evidence, to help create guidelines and quality of care, and also move the field forward. Thank you. So let me take a few minutes for a discussion that we have panned out, knowing that we started a little bit late. So there's two general categories, I think, where PERT teams start. One is PERT teams starting in a vacuum, and I think we have a great discussion on that coming up later with Dr. Patel. And then one, which is probably the other most common question I get, is about, well, what do you do about the turf wars? So when we're talking about reaching across the aisle, especially as you were building the program in Northwell, how did you guys deal with that? I think, as you know, in New York there's a lot of turf wars. I think you have to come to the table and be willing to work with other specialties. I think it's a lot of education between the fields about what you can offer the patient. And I think you have to do a couple of cases, and I think you have to work together. Invite them to come to the cath lab to help you with something. Go to the OR and watch them do a surgical embolectomy. We put patients on ECMO in the cath lab, so there's already that relationship going on. And I think also it's—you have to review the cases. Every month we're reviewing all the PERT cases we do for that month to look about outcomes and see where things went wrong, where we have means for improvement. I think you just have to be positive. I think it's an exciting field. I think lots of people want to be part of this and move the field forward. And I think just being optimistic and just being supportive, I think, is very important. That's great. You know, Texas and New York are a little different, but I think the answer to the question is the same. It's easy to do the procedures at the end of the day. You can ECOS someone in 15 minutes. Thrombectomy is not the hardest thing to do in the world. What's difficult is building the system. And I know the frontline providers that see those patients—the hospitalists, the ICU doctors, the ER doctors—they're really looking for that ease of activation and who's going to be following up the patient after and who's going to be taking the phone call about how to dose systemic thrombolytic and all those pieces of the puzzle. I think as cardiologists, we're uniquely situated to do that work, and I think that makes a lot of sense.

multidisciplinary team approach

pulmonary embolism patients

collaboration

PE response team

improving outcomes