COMMENTARY

How Multidisciplinary Pulmonary Embolism Response Teams Work

Samuel Z. Goldhaber, MD

Disclosures

July 18, 2016

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This is Dr Sam Goldhaber for the Clot Blog at theheart.org on Medscape, speaking to you from the American College of Cardiology meeting in Chicago.

Today I'm going to speak about multidisciplinary pulmonary embolism response teams. P-E-R-T or PERTs, as they're known,[1] are springing up across the country. They're springing up because there is often a lot of disagreement or at least uncertainty about how best to manage complicated acute pulmonary embolism patients who present with submassive or massive pulmonary embolism.

The philosophy behind these PERTs is that the best management requires a multidisciplinary approach: an approach from the cardiologist or vascular medicine specialist, coupled with secure reading of the subtleties of the cardiovascular imaging; an opinion of a cardiovascular or interventional radiologist, perhaps with a cardiac surgeon who might decide to take the patient for open surgical embolectomy.

When these very sick patients present to the hospital, a preprogrammed beeper summons all of the necessary disciplines to come formulate an opinion. It turns out that most of these submassive and massive pulmonary embolism patients present on the weekend, often in the middle of the night. I'd say that the popular times are between 1 AM and 4 AM, and on important holidays like Christmas Eve or the Fourth of July or New Year's Eve. So, the way these are approached is often with a webinar, which is set up so that collectively, in a Web-based conference, the imaging can be displayed—particularly the chest CT scan. Then the cath lab interventionalist with the medical physician, the vascular medicine specialist, or the pulmonologist or cardiologist, coupled with the cardiovascular imaging specialist and sometimes with a cardiac surgeon, can think out the pros and cons of using advanced therapy rather than anticoagulation alone.

Advanced therapy includes placement of an inferior vena cava filter; taking the patient to the cath lab or interventional radiology lab for catheter-directed thrombolysis, often with ultrasound-facilitated catheter-directed thrombolysis with low-dose tissue plasminogen activator; sometimes systemic administration of thrombolytic therapy; and sometimes open surgical embolectomy. These are complex decisions. There is often no easy protocol that can be preplanned to [dictate] what should be done for a particular patient. The decisions also often depend on the patient's comorbidities and on patient preference and family preference.

The idea of the PERT team is to present a consensus suggestion to the primary team and to talk with the primary team and with the patient and family about the various options. Fortunately, we live in an era where many effective approaches are available. Some rely on advanced therapy above and beyond anticoagulation. Such therapy is best practiced with a multidisciplinary approach.

This is Dr Sam Goldhaber, signing off for the Clot Blog.

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