PowerPoint Presentation (PDF) - Perfusion.com

PHILADELPHIA, PENNSYLVANIA

Acute Massive Pulmonary Embolism (AMPE)
The Aria Health Experience:-
Rapid Response and Two Surgical Techniques which resulted in
100% positive outcome in the cardiac operating room.
H.MOHAMED, CCP., J.SCHULTZ, CCP., T.ZOMBOLAS, CCP., R. METCALF, MD.

Recent National Incidents:
February 2011:
Transgender hip-hop singer from Philadelphia sought for the
death of a young British female entertainer.
March 2011:
Tennis star Serena Williams, on a flight from NY to LA,
suffered from a PE.

OBJECTIVE / PURPOSE:AMPE
- Raise an awareness with causes and complications
- Review the multidisciplinary team approach to treatment:
- Perfusionist, Surgeon, Anesthesiologist, Intensivist,
Radiologist
- Stat admission to the Cardiac OR
- Assessment of RV Function / Strain
- Assessment of Lung Function
- Review / Discuss our experience and treatment
- Highlight a possible new treatment approach with new equipment

HISTORY
1872 - Dr. Trendelenburg studied 9 hospitalized patients with PE. He
performed 2 pulmonary embolectomies and both patients died within
37 hours.
1924 - Dr. Kirschner, a student of Trendelenburg, performed the first
successful pulmonary embolectomy. This case was presented at the
Berlin Surgical Conference. Dr. Oschner from the USA attended this
conference and took note of the procedure.
1932 - Drs. Oschner and Debakey advocated IVC ligation to prevent
pulmonary embolus.
1932 - While a surgical resident, Dr. Gibbon witnessed an
unsuccessful open attempt to save the life of a young woman who had
sustained a pulmonary embolus - this was the catalyst for the
development of the Heart / Lung Machine.
1934 - Dr. Homans performed the first prophylactic venous ligation.

HISTORY cont’d.
1961 - Dr. Cooley attempted a pulmonary embolectomy
using CPB.
1962 - Dr. Sharp performed the first successful pulmonary
embolectomy in the United States.
Two surgical approaches ultimately evolved for the
management of pulmonary embolus.
1. Operations that focused on the removal of an embolus
to the lung.
2. Operations that were designed to prevent embolization.
Note: Sudden interruption of vena cava flow caused a
decreased cardiac output and severe peripheral edema

Background Information
-“Pulmonary embolism is a life-threatening condition that occurs
when a thrombus or other material blocks the pulmonary arterial
system in your lungs”.
-This is an extremely common and highly lethal condition that is a
leading cause of death in all age groups.
-One of the most prevalent disease processes responsible for
in-patient mortality (30-50%)
-Overlooked diagnosis.

Why is this clinical picture of PE so important?
Prompt diagnosis and treatment can dramatically reduce the
mortality and morbidity rate.
Majority of the cases are unrecognised clinically.
One third of the patients who survive an initial PE die of a future
embolic episode.
Many patients who die of PE have not had any diagnostic workup
nor have they received any prophylaxis for the disease.
In most cases, the CLINICIANS have not even considered the
diagnosis of PE.

Pathophysiology
PE is not a disease in and of itself.
It is often a fatal complication of underlying venous
thrombosis.
Normally microthrombi (RBC,Platelets and Fibrin) are formed
and lysed within the venous circulatory system.
Under pathological conditions, these microthrombi may
escape, propagate and will block the pulmonary blood vessels
causing PE.

Facts about PE.
3 rd most common cause of death.
2 nd most common cause of unexpected death in most age
groups.
60% of patients dying in the hospital have had a PE.
Diagnosis has been missed in about 70% of the cases

National Statistics
There are approximately 650,000 occurrences in the United States.
400,000 of these patients go undiagnosed.
The Center for Disease Control (CDC) estimated that about 250,000
Americans annually suffer from a PE.
About 100,000 deaths occur annually and these could have been
prevented with proper diagnosis and treatment.

National Statistics cont’d.
This type of obstruction can manifest itself into a myriad of
physiologic events which can ultimately result in cardiac arrest and
death of up to 70-90% of these patients in the first hour.
Approximately 75% of autopsy-proven Pulmonary Embolisms (PE)
are not detected clinically.

National Statistics cont’d.
African Americans are the highest risk group with a 50%
higher incidence than American Whites.
Asian/Pacific Islanders/American Indian patients have a
markedly lower risk.
The risk factor is increased in pregnancy and during the
postpartum period.
The mortality rate remains 20-30% higher in men than in
women.

RECOMMENDATIONS
CPB for pulmonary embolism should be utilized for those
patients who are hypotensive (systolic pressure

Definition
A pulmonary embolus is described as a blockage of the:
- Main Pulmonary Artery (PA).
- The Right and/or Left Pulmonary Arteries.
- The Segmental Pulmonary Arteries.
…by either a blood clot (thrombus), fat, gas (nitrogen, air, CO 2),
tumor cells, amniotic fluid, septic embolism, talc or elemental
mercury and more recently silicone.

Silicone Embolus
Former Miss. Argentina (1994) died in December 2009 from
silicone complications of a “gluteal plasty” which involved
injection of liquid silicone.
In November 2006, this occurrence (44 patients) was presented at
the annual meeting of the Radiological Society of North America
(RSNA) where the idea of “Pump Up” parties was discussed for the
very first time.
Often members of the male-to-female transgender community
gather for liquid silicone injections in hopes of feminizing their
appearance.

Definition cont’d.
Medically, AMPE is defined as an occlusion of the PA that exceeds
50% of its cross sectional area, resulting in progressive
hemodynamic compromise.
Massive PE is also defined as the presence of persistent systemic
hypotension or cardiogenic shock and signs of right ventricular
dysfunction (RVD).
A sub-massive PE is defined as moderate to large clot, presence of
RVD, and normal arterial blood pressure.

SIGNS AND SYMPTOMS:
Signs and symptoms of PE may include any or all of the
following:
∙chest pain at rest ∙anxiety
∙S.O.B. at rest ∙dizziness
∙hyperventilation ∙diaphoresis
∙syncope ( B/P, CO, PAP) ∙tachycardia (>100 b/p/m) ∙clammy
skin ∙hemoptysis (13%)
∙swollen/painful legs ∙wheezing/crackles
∙apnea ∙peripheral cyanosis
∙dyspnea (73%) ∙painful respirations
∙cough (37%) ∙fever
∙pleuritic chest pain (66%) ∙T wave inversions (leads V1-4)

TESTS USED TO CONFIRM PE:
∙Quantitative D-dimer assay test* ∙Ventilation/perfusion Scan ( V/Q) ∙Pulse Oximetry ∙CT Angiography
∙Pulmonary Arteriogram ∙CT Scan (helical)
∙Doppler Ultrasonography ∙Hemodynamics
∙Venogram of the leg ∙Arteriogram of the leg
∙Arterial Blood Gas (ABG) ∙EKG (S-T in V1- 4)
∙Physical exam/family history or prior Deep Vein Thrombosis (DVT)/PE
∙Echocardiography
*D-dimer ASSAY TEST:
The Quantitative D-dimer assay test is also referred to as the “Fibrin
Degradation test” or “Fragment D-dimer”. The Fragment D-dimer assesses both
thrombin and plasmin activity. Related tests may include; Fibrin Split Products
(FSP), Fibrin Degradation Products (FDP), Prothrombin Time (PT), Partial
Thromboplastin Time (PTT); Fibrinogen, and or Platelet count.

TREATMENT OF PE:
First Line Treatment: NON-ACUTE SITUATION
∙O 2 Therapy
∙Intubation/Ventilation
∙Insertion of Vena Caval Filter
Bird’s nest filter (Infrarenal)
Greenfield filter (Suprarenal)
∙Sildenafil (Viagra)
∙Anticoagulant/Thrombolysis
-Heparin
-Coumadin
-Tissue Plasminogen Activators (TPA)
∙Low Molecular Weight Heparin

TREATMENT OF PE: cont’d
Second Line Treatment: ACUTE SITUATION
∙Surgical removal with the use of CPB
∙*Surgical removal with the Vortex Angiovac cannula
(new technique)
∙Intubation / Ventilation
∙O 2 Therapy
∙Insertion of Vena Caval Filter
Bird’s nest filter (Infrarenal)
Greenfield filter (Suprarenal)
∙Anticoagulant/Thrombolysis
-Heparin
-Coumadin
-TPA
-Low Molecular Weight Heparin

AngioVac System
Right Femoral 22 fr.to Left Femoral 18 fr. venous bypass.
Utilizing a centrifugal pump and no oxygenator in line.
Tracking over an Amplatz stiff wire, the AngioVac cannula is
positioned first in the main PA. The balloon actuated funnel tip on
the AngioVac is then opened and the pump flow is initiated and
then optimized.

Vortex Medical Inc.
AngioVac System

∙Sudden Cardiac death
COMPLICATIONS OF PE:
∙Long term anticoagulant prophylaxis potentially leading to
bleeding problems
∙Right Ventricular Hypertophy (RVH) / Cor Pulmonale
∙Respiratory Failure
∙Cardiogenic shock ( C.O., B/P)
∙Palpitations

Regular exercise
Anticoagulant prophylaxis
Hydration
Alcohol intake (decrease)
Use of compression stockings
PREVENTION OF PE:
Mobilization when taking long travel trips
Use professionals for cosmetic surgeries

Chest X-Ray of PE

Pulmonary Angiogram

Pulmonary Angiogram X-Ray

Contrast CT showing Pulmonary Embolus

The Aria Experience
Methods: Two Cardiopulmonary Bypass Techniques
- Deep Hypothermic Circulatory Arrest (DHCA)
with Cold Retrograde Cerebral Perfusion (RCP)
(n=7)
- Normothermic (Tepid)
(n=13)

DHCA Technique (Group A)
Cannulation: Aortic & Bi-Caval Venous Cannulation
Cardioplegia administration: Antegrade/Retrograde (warm/cold)
Systemic cooling: As per protocol to 18 o C
Circulatory Arrest: Initiation
Initiation of RCP: Flow & pressure as per protocol
Surgical removal of PE
Cessation of RCP
Rewarm as per protocol
Administration of warm retrograde blood only to the heart
TEE Assessment
Termination of CPB (See table 1-Group A)

Population
Group A (Circ. Arrest)
7
Average Age Male = 48.8 /Female = 33
Sex Male = 6 Female = 1
Mean Arterial Pressure 80 (mmHg)
Mean PA Pressure n /a* (mmHg)
Mean CVP (20-30 mmHg) (SVC)
Average Retrograde
Cerebral Blood flow
260 mL/min (180-350)
Mean SvO2 (CPB) 82
Mean Pre Bypass rSO2
52
Mean Cooling rSO2
77
Mean RCP rSO2
85
Mean Warming rSO2
73
Cannulation Same
(AO/IVC/SVC)
Average Pump Time 135 Min.
Average Crossclamp 41Min.
Time
Average Circ Arrest 41 Min. (30-66)
Time
Lowest temperature
13
during Circ. Arrest
o C
Average Cooling Time 52 Min.
Average Rewarming 77 Min.
Time
* = No PA line was inserted into the Pulmonary Artery pre-CPB.

Normothermic (Tepid) Technique
Cannulation: Aortic & Bi-Caval venous cannulation (Mitral valve)
Cardioplegia administration: Antegrade/Retrograde (warm/cold)
15 minutes intervals
Systemic temperature: Drift to no less than 34 o C
Surgical removal of PE
Rewarm to 37 o C
Administration of warm retrograde blood only to the heart
TEE Assessment
Termination of CPB (See table 1-Group B)

Group B (Normothermic)
-Drift to 34 o Population
C
13
Average Age Male = 54.2 /Female = 49.3
Sex Male = 5 Female = 8
Mean Arterial Pressure 95 (mmHg)
Mean PA Pressure n /a* (mmHg)
Mean CVP ?
Average Retrograde
Cerebral Blood flow
0
Mean SvO2 (CPB) 72
Mean Pre Bypass rSO2
52
Mean Cooling rSO2
NA
Mean RCP rSO2
NA
Mean Warming rSO2
68
Cannulation Same
Average Pump Time 64 Min.
Average Crossclamp Time 45 Min.
Lowest temperature
during CPB
34 o C
Average Cooling Time 0
Average Rewarming Time 15
* = No PA line was inserted into the Pulmonary Artery pre-CPB.

Group A (Circ. Arrest) Group B (Normothermic)
-Drift to 34 o C
Population 7 13
Average Age Male = 48.8 /Female = 33 Male = 54.2 /Female = 49.3
Sex Male = 6 Female = 1 Male = 5 Female = 8
Mean Arterial Pressure 80 (mmHg) 95 (mmHg)
Mean PA Pressure n /a* (mmHg) n /a* (mmHg)
Mean CVP (20-30 mmHg) (SVC) ?
Average Retrograde 260 mL/min (180-350)
0
Cerebral Blood flow
Mean SvO2 (CPB) 82 72
Mean Pre Bypass rSO2 52 52
Mean Cooling rSO2 77 NA
Mean RCP rSO2 85 NA
Mean Warming rSO2 73 68
Cannulation Same
Same
(AO/IVC/SVC)
Average Pump Time 135 Min. 64 Min.
Average Crossclamp Time 41Min. 45 Min.
Average Circ Arrest Time 41 Min. (30-66) 0
Lowest temperature
13 o C 34 o C
during CPB
Average Cooling Time 52 Min. 0
Average Rewarming Time 77 Min. 15
* = No PA line was inserted into the Pulmonary Artery pre-CPB.

BLOOD GASES
Pre Intubation pH CO 2 O 2
Normothermic 7.436 (7.37-7.52) 35 (27-56) 70.2 (56-86)
Circ. Arrest 7.325 (7.25-7.40) 41 (27-55) 75.5 (58-93)**
On CPB pH CO 2 O 2
Normothermic 7.352 (7.27-7.41) 40.9 (31-53) 328.7 (173-488)
Circ. Arrest 7.281 (7.10-7.47) 52.4 (40-70) 539 (408-696)
Post Bypass pH CO 2 O 2
Normothermic 7.376 (7.30-7.47) 40.5 (29-48) 305.2 (105-487)
Circ. Arrest 7.314 (7.25-7.37) 44.1 (36-59) 126 (64-218)***
** = Demonstrating gas exchange problems
*** = Still denoting gas exchange problems

Summary
The Keys to Our Management Strategy
- Mandatory multidisciplinary approach.
- 24/7 availability.
- Rapid and a precise diagnosis with an immediate transfer to the
CTOR (resembling Rescue Therapy) (LIKE VAD/ECMO)
- Execution of a precise care plan by - Perfusionist
- Surgeon
- Intensivist
- Radiologist
- Anesthesiologist
- ICU staff
- Results - 100% survival rate in the CTOR

Summary cont’d
In a nonrandomized comparison of surgical and medical treatment
in hemodynamically compromised patients with massive PE, the
medical group had an increased mortality rate, increased number
of hemorrhagic events and a higher incidence of recurrent PE.
Gulba DC, Schmid C, Borst HG, Lichtlen P, Dietz R, Luft FC. Medical compared with Surgical Treatment for
Massive Pulmonary Embolism. Lancet. 1994:343:576-577.
Currently our practice uses only the “tepid” CPB approach when
we treat Acute Massive Pulmonary Embolism.

Thank You
Questions????