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PERT and Ecmo

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The Ecmologist

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The Pulmonary Embolism Response Team (PERT) is a multidisciplinary team of medical specialists dedicated to the rapid assessment, diagnosis, and treatment of patients with acute pulmonary embolism (PE). PE is a potentially life-threatening condition where a blood clot blocks one or more arteries in the lungs, leading to symptoms like shortness of breath, chest pain, and, in severe cases, cardiac arrest.

Purpose of PERT

The primary goal of a PERT is to provide timely, coordinated, and expert care to patients with PE, particularly those with high-risk or intermediate-high-risk PE. The team evaluates the severity of the embolism and decides on the most appropriate treatment strategy, which can range from anticoagulation to advanced interventions.

Who is on the PERT?

The team typically includes specialists from various fields, such as:

  1. Cardiology: For heart-related complications.
  2. Pulmonology: For lung function and respiratory support.
  3. Hematology: For blood clotting disorders and anticoagulation management.
  4. Critical Care Medicine: For patients requiring intensive care.
  5. Interventional Radiology: For catheter-based procedures (e.g., thrombectomy).
  6. Cardiothoracic Surgery: For surgical embolectomy if needed.
  7. Emergency Medicine: For initial stabilization and triage.
  8. Pharmacology: For anticoagulation and thrombolytic therapy.

When is PERT Activated?

PERT is typically activated for patients with:

  • High-risk (massive) PE: Signs of hemodynamic instability (e.g., low blood pressure, shock).
  • Intermediate-high-risk PE: Evidence of right heart strain or elevated biomarkers (e.g., troponin, BNP) without hemodynamic instability.
  • Complex cases: Patients with comorbidities, contraindications to standard therapies, or unclear treatment pathways.

Treatment Options Managed by PERT

The PERT evaluates the patient and tailors treatment based on the severity of the PE and the patient’s overall condition. Options include:

  1. Anticoagulation: Blood thinners (e.g., heparin, direct oral anticoagulants) to prevent further clot formation.
  2. Thrombolysis: Clot-busting drugs (e.g., alteplase) to dissolve the clot.
  3. Catheter-Directed Interventions:
  • Thrombectomy: Mechanical removal of the clot.
  • Thrombolysis: Localized delivery of clot-busting drugs.
  1. Surgical Embolectomy: Surgical removal of the clot in severe cases.
  2. ECMO (Extracorporeal Membrane Oxygenation): Temporary heart and lung support for patients in cardiogenic shock or refractory hypoxia.

Benefits of PERT

  • Rapid decision-making: Streamlines the evaluation and treatment process.
  • Multidisciplinary expertise: Combines the knowledge of various specialists to optimize care.
  • Improved outcomes: Studies have shown that PERT activation is associated with lower mortality rates and better patient outcomes.
  • Tailored treatment: Ensures that each patient receives the most appropriate therapy based on their specific condition.

PERT in Action

  1. Initial Assessment: The team reviews imaging (e.g., CT pulmonary angiogram), echocardiogram, and biomarkers to assess the severity of the PE.
  2. Risk Stratification: Determines whether the patient is at low, intermediate, or high risk.
  3. Treatment Plan: Decides on the best course of action, which may involve a combination of therapies.
  4. Follow-Up: Monitors the patient’s progress and adjusts treatment as needed.

Outcomes

  • PERT has been shown to reduce mortality and improve outcomes in patients with acute PE, particularly in high-risk cases.
  • It also helps standardize care and ensures that patients receive evidence-based treatments.

Pulmonary Embolism (PE) and ECMO (Extracorporeal Membrane Oxygenation) are closely linked in the management of severe, life-threatening cases of PE.

How is ECMO used in patients with pulmonary embolism?

Pulmonary Embolism (PE)

  • Definition: PE occurs when a blood clot (usually from the deep veins of the legs, known as deep vein thrombosis or DVT) travels to the lungs and blocks one or more pulmonary arteries.
  • Symptoms: Shortness of breath, chest pain, cough, rapid heart rate, and, in severe cases, hemodynamic instability (low blood pressure, shock) or cardiac arrest.
  • Severity:
  • Low-risk PE: Stable patients with no signs of right heart strain.
  • Intermediate-risk PE: Evidence of right heart strain (e.g., on echocardiogram or elevated biomarkers) but no hemodynamic instability.
  • High-risk (massive) PE: Hemodynamic instability (e.g., shock, low blood pressure) or cardiac arrest.

ECMO (Extracorporeal Membrane Oxygenation)

  • Definition: ECMO is a form of advanced life support that temporarily takes over the function of the heart and/or lungs when they are severely failing.
  • Types:
  1. Venovenous (VV) ECMO: Provides respiratory support by oxygenating the blood and removing carbon dioxide. Used for severe respiratory failure.
  2. Venoarterial (VA) ECMO: Provides both cardiac and respiratory support. Used for heart failure or cardiogenic shock.
  • How it works: Blood is pumped out of the body, oxygenated by a machine, and then returned to the body.

Use of ECMO in Pulmonary Embolism

ECMO is typically considered in high-risk (massive) PE when the patient is in cardiogenic shock or refractory hypoxia (low oxygen levels despite maximal support). It serves as a bridge to recovery or a bridge to definitive treatment.

Indications for ECMO in PE

  1. Cardiogenic shock: When the heart cannot pump effectively due to the clot.
  2. Refractory hypoxia: When the lungs cannot oxygenate the blood despite mechanical ventilation and other support.
  3. Cardiac arrest: ECMO can be used during resuscitation (ECPR, or extracorporeal cardiopulmonary resuscitation) in cases of PE-related cardiac arrest.
  4. Bridge to definitive treatment: ECMO stabilizes the patient while preparing for interventions like thrombolysis, thrombectomy, or surgical embolectomy.

How ECMO Helps in PE

  1. Stabilizes hemodynamics: VA-ECMO supports the heart and lungs, maintaining blood pressure and oxygenation.
  2. Buys time: Allows the medical team to evaluate and perform definitive treatments (e.g., thrombolysis, thrombectomy).
  3. Reduces right heart strain: By oxygenating the blood and reducing the workload on the heart, ECMO can help the right ventricle recover.

Definitive Treatments for PE While on ECMO

Once the patient is stabilized on ECMO, the following treatments may be pursued:

  1. Systemic thrombolysis: Clot-busting drugs (e.g., alteplase) to dissolve the clot.
  2. Catheter-directed thrombolysis or thrombectomy: Minimally invasive procedures to remove or dissolve the clot.
  3. Surgical embolectomy: Open surgery to remove the clot (rare but may be necessary in severe cases).

Outcomes of ECMO in PE

  • ECMO has been shown to improve survival in patients with massive PE and cardiogenic shock or cardiac arrest.
  • However, ECMO is a high-risk intervention and requires careful patient selection, as complications can include bleeding, infection, and vascular injury.

When is ECMO Not Suitable?

ECMO may not be appropriate for patients with:

  • Irreversible brain injury.
  • Advanced terminal illness.
  • Severe comorbidities that limit survival or quality of life.

Key Points

  • ECMO is a rescue therapy for severe PE when other treatments fail or are contraindicated.
  • It is most effective when used as part of a multidisciplinary approach, often involving a Pulmonary Embolism Response Team (PERT).
  • Early recognition of PE and timely initiation of ECMO can save lives in critical cases.

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