Faculty Bibliography

Pulmonary embolism response teams (PERTs) are being increasingly used for the management of patients admitted with acute pulmonary embolism (PE) and are endorsed by societal guidelines. Whether PERT improves outcomes remains unknown. The objective of this meta-analysis was to compare the outcomes of patients with acute PE treated by a PERT versus no PERT.A systematic review and study level meta-analysis was conducted by searching PubMed and EMBASE databases from inception until November 10, 2024 and included studies evaluating efficacy of PERT vs no PERT in patients admitted for acute PE. Outcomes included all-cause mortality (in-hospital and 30-day mortality), major and clinically relevant bleeding, advanced therapies utilization, length of stay (LOS), and 30-day readmission. Twenty-four retrospective observational studies met the inclusion criteria, comprising 15,809 patients (mean age 61.6 years with 49% male) with acute PE of which 6228 were treated with a PERT and 9,581 without a PERT. Lower all-cause mortality (in-hospital or 30-day mortality) [odds ratio (OR)= 0.72; 95% CI: 0.56 to 0.93; 24 studies], major or clinically relevant bleeding (OR= 0.60; 95% CI: 0.42 to 0.86; 15 studies), higher utilization of advanced therapies (OR= 3.16; 95% CI: 1.81 to 5.49; 19 studies), and lower hospital LOS (MD= -1.49; 95% CI: -2.59 to -0.39; 14 studies) were seen in the patients treated by a PERT compared to those not treated by a PERT. In this large meta-analysis of observational studies comparing outcomes in patients treated by PERT versus not treated by PERT, there were significantly lower short-term mortality, lower major or clinically relevant bleeding, higher utilization of advanced therapies and lower hospital length of stay with the existence of PERT. PERT should be the standard of care for the management of patients with acute PE.

BACKGROUND:Pulmonary embolism (PE) is can present with cardiac arrest. Catheter-based therapies (CBT) provide rapid reperfusion for patients with PE, though their effect on outcomes of patients with PE and cardiac arrest are not well known. AIMS/OBJECTIVE:To evaluate the effect of CBT on outcomes among patients with PE and cardiac arrest. METHODS:This was a retrospective cohort study of patients with PE and cardiac arrest from 2017 to 2020, using the National Readmission Database (NRD). We compared patients who underwent CBT versus no CBT and patients managed with CBT alone versus systemic thrombolysis alone. The primary endpoint was in-hospital death; exploratory outcomes were 90-day death and readmissions. Multivariable logistic and Cox proportional hazards modeling were used. RESULTS:Nine hundred and seventy-three patients were included (111 with CBT). CBT was associated with a lower risk of in-hospital death (36.9% vs. 49.3%, p = 0.015; aOR 0.44, 95% CI 0.23-0.85) with no difference in 90-day readmission (11.3% vs. 18.7%, p = 0.19; aHR 0.63, 95% CI 0.27-1.47). Among the 390 patients with either CBT or systemic thrombolysis alone in-hospital death (34.4% vs. 48.5%, p = 0.023; aOR 0.51, 95% CI 0.21-1.25) and 90-day readmissions (13.3% vs. 11.8%, p = 0.79; aHR 1.04, 95% CI 0.39-2.76) were similar. Ninety-day survival was higher with CBT when compared with no CBT or systemic thrombolytic alone (log-rank p = 0.050 and 0.020, respectively). CONCLUSIONS:Among patients with PE and cardiac arrest, CBT was associated with decreased risk of in-hospital death and 90-day survival compared with no CBT. Further prospective study on utility of CBT in PE and cardiac arrest is needed.

BACKGROUND:Mixed cardiogenic and septic shock has been shown to have a higher mortality than cardiogenic shock alone and presents a unique hemodynamic phenotype. OBJECTIVES/OBJECTIVE:This study aimed to evaluate whether higher circulatory support with veno-arterial extracorporeal life support (VA-ECLS) was associated with increased survival to discharge in patients with mixed shock. METHODS:flow) circulatory support on VA-ECLS at 24 hours post-ECLS initiation. RESULTS:A total of 452 patients supported with VA-ECLS with mixed shock were identified. Overall mortality was 63% (n = 285). Older age (adjusted OR [aOR]: 1.02; 95% CI: 1.01-1.04; P < 0.001), pre-extracorporeal membrane oxygenation cardiac arrest (aOR: 1.71; 95% CI: 1.11-2.65; P = 0.016), and baseline Charlson Comorbidity Index (aOR: 1.13; 95% CI: 1.01-1.28; P = 0.043) were associated with increased mortality. Patients receiving higher VA-ECLS support at 24 hours were numerically more likely to survive to discharge (42.6% vs 33.8%, P = 0.063). When evaluated as a continuous variable, higher VA-ECLS flow at 24 hours was associated with an aOR of 1.31 (95% CI: 0.87-1.97; P = 0.19) for survival to discharge. CONCLUSIONS:Patients with mixed shock requiring VA-ECLS have a high mortality. Patients with mixed shock receiving higher support at 24 hours had a trend toward increased survival to discharge compared to those with lower support. These results are hypothesis-generating, and further studies are needed.

BACKGROUND:The relationship between syncope and invasive hemodynamics in patients with pulmonary embolism (PE) remains unknown. The objective of this study was to assess the ability of syncope, as a single clinical variable, to predict a low cardiac index in patients with acute PE. METHODS:) in patients with acute intermediate- high risk PE. Secondary outcomes included 30-day mortality, hemodynamic instability, 90-day readmission rates, other invasive hemodynamic parameters, intensive care unit (ICU) length of stay (LOS), and hospital LOS. Regression analyses were used to evaluate the association between cardiac index and syncope. RESULTS:A total of 132 patients (86% intermediate- and 14% high-risk) were included in the study, with 27 (20%) presenting with syncope. Among the 114 intermediate-risk patients, 24 (21%) presented with syncope. In all-comers, there was no significant difference between groups at baseline. Within the intermediate-only subgroup, there were no significant differences between groups at baseline, except that the syncope group was older (62.6 ± 14.9 vs. 56.1 ± 13.9, p=0.048, Table 2) and had significantly higher troponin elevation at presentation (684.3 ± 1361.8ng/L vs. 195.6 ± 278.1ng/L, p=0.003, Table 2). In all-comers, there was no difference in rates of low cardiac index (63% vs. 59%, p=0.71) or mPAP (33.9 ± 8.6 vs. 32.7 ± 9.6 mm Hg, p=0.57) between patients who presented with and without syncope. Similarly, among intermediate-risk patients, there was also no difference in the rates of low cardiac index (67% vs. 57%, p=0.38) or mPAP (34.0 ± 9.2 vs. 33.1 ± 9.8 mmHg, p=0.69) between patients with and without syncope. There was no difference in clinical outcomes between those who presented with and without syncope. CONCLUSION/CONCLUSIONS:In conclusion, in patients with acute PE, syncope was not associated with a low cardiac index or higher mPAP.

BACKGROUND:The recently published PEERLESS trial compared catheter-directed thrombolysis (CDT) and catheter-based thrombectomy (CBT) in acute pulmonary embolism (PE). However, it included a low proportion of patients with contraindications to thrombolytic therapy (4.4%), leaving uncertainty about how CDT would perform relative to CBT in a real-world cohort with higher bleeding risk. AIMS/OBJECTIVE:This study aims to address this gap by comparing real-world outcomes of CDT and CBT in patients with acute PE. METHODS:This retrospective analysis included patients who underwent CDT and CBT at two tertiary care centers from January 2020 to January 2024. The primary outcome was a composite of 30-day mortality, resuscitated cardiac arrest, or hemodynamic decompensation. Secondary outcomes included major bleeding and intracranial hemorrhage (ICH). Inverse probability treatment weighting (IPTW) was used to adjust for baseline variables. RESULTS:A total of 162 (mean age 58 years, 45.7% women, 17.3% high-risk, 28% contraindication to lytics, 28% CDT, 72% CBT) patients were included, with 12.4% patients experiencing the primary outcome. There was no difference in the rates of the primary outcome between CBT versus CDT (11.2% vs. 15.2%, IPTW HR: 0.80; 95% CI: 0.27-2.38, p = 0.69). CBT was associated with a lower risk of hemodynamic decompensation (5% vs. 21.7%, p = 0.036), major bleeding (7.8% vs. 17.4%, IPTW HR 0.26; 95% CI: 0.07-0.95, p = 0.042) and ICH (0 vs. 4.3%, p = 0.024) compared to CDT. CONCLUSION/CONCLUSIONS:Among a real-world cohort of patients with acute PE with higher bleeding risk than PEERLESS undergoing catheter-based therapies, CBT was associated with a lower rate of hemodynamic deterioration, major bleeding, and ICH with similar rate of primary composite outcome when compared with CDT. Additional randomized controlled trials are needed to validate these findings.

INTRODUCTION/BACKGROUND:This study explores the implementation and outcomes of catheter-based thrombectomy (CBT) for acute pulmonary embolism (PE) within a safety-net hospital (SNH), addressing a critical gap in the literature concerning CBT in underserved and vulnerable populations. METHODS:This is a retrospective study of patients undergoing CBT between October 2020 and January 2024 at a SNH. The primary outcome was 30-day all-cause mortality. RESULTS:A total of 107 patients (47.6 % female, mean age 58.4 years) underwent CBT for acute PE, with 23 (21.5 %) high-risk and 84 (78.5 %) intermediate-risk PE. Demographically, 64 % identified as Black, 10 % White, 19 % Hispanic or Latino, and 5 % Asian. In terms of insurance coverage, 50 % had private insurance or Medicare, 36 % had Medicaid, and 14 % were uninsured. Notably, 67 % of the patients resided in high poverty rate zip codes and 11 % were non-citizen non-residents. Over a median follow up period of 30 days, 6 (5.6 %) patients expired (all high-risk PE), 3 of whom presented with cardiac arrest. No patients who presented with intermediate-risk PE died at 30 days. There was no difference in 30-day mortality based on race, insurance type, poverty level or citizenship status. CONCLUSION/CONCLUSIONS:Our study findings reveal no disparities in access or outcomes to CBT at our SNH, emphasizing the feasibility and success of implementing PERT and CBT at a SNH, offering a potential model to address healthcare disparities in acute PE on a broader scale.

BACKGROUND:Acute pulmonary embolism (PE) is a common cause of cardiovascular morbidity and mortality. Catheter-based therapies (CBT) are emerging technologies that provide reperfusion for patients with PE. However, the optimal timing of these interventions from initial presentation is unknown. AIMS/OBJECTIVE:This study aimed to determine whether the timing of CBT affects outcomes among patients with acute PE managed with CBT. METHODS:This was a retrospective cohort study of patients with PE who underwent CBT and were included in the Nationwide Readmissions Database between January 2017 and December 2020. Patients who underwent early CBT (≤1 day from admission) were compared with those who underwent delayed CBT (>1 day). The primary outcome was death at 90 days, and secondary outcomes included 90-day readmissions. Propensity scores were estimated using logistic regression, and propensity score weighting (PSW) was utilised to compare outcomes between early and delayed CBT. Cox proportional hazards modelling was used to estimate the risk of primary and readmission outcomes. RESULTS:A total of 12,137 patients were included: 1,992 (16.4%) had high-risk PE, and 1,856 (15.3%) were treated with delayed CBT. After PSW, early CBT was associated with a lower risk of 90-day death in both intermediate-risk (hazard ratio [HR] 0.55, 95% confidence interval [CI]: 0.46-0.66) and high-risk (HR 0.89, 95% CI: 0.80-0.99) PE. Early CBT was associated with lower rates of all-cause readmission in patients with intermediate-risk PE (HR 0.86, 95% CI: 0.78-0.95) and in those with high-risk PE (HR 0.84, 95% CI: 0.69-1.05). CONCLUSIONS:Among patients with intermediate- or high-risk PE, early CBT was associated with a lower risk of 90-day death and readmission. A further prospective study on the optimal timing for reperfusion using CBT is needed.

BACKGROUND:Cardiogenic shock (CS) is a common complication of acute coronary syndrome (ACS) and is associated with significant morbidity and mortality. Revascularization has been shown to reduce mortality in ACS-CS. Patients with cancer are at high risk of ACS and CS. However, patients with cancer are often undertreated with invasive procedures and outcomes of patients with cancer and ACS-CS have not been thoroughly characterized. METHODS:Patients with ACS-CS from 2014 to 2020 with and without cancer were identified using the National Readmission Database (NRD). Primary outcome was death at 90-days. Secondary outcomes were 90-day cardiovascular (CV) and bleeding readmissions, and index hospitalization major bleeding and thrombotic complications. Patients with cancer were compared to patients without cancer using multivariable logistic and Cox proportional hazards regression. Temporal trends in revascularization among patients with and without cancer were examined. Effect of revascularization among patients with cancer and ACS-CS was assessed using propensity score weighting (PSW). RESULTS:A total of 140,205 patients were identified, of whom 6118 (4.4 %) with cancer were identified. Patients with cancer were less likely to undergo percutaneous coronary intervention (45.5 % vs 53.5 %) or be managed with mechanical circulatory support (36.6 % vs 46.0 %). After multivariable logistic regression, there was no difference in primary outcome (adjusted OR 0.98, 95 % CI 0.92-1.06) but patients with cancer had higher risk of 90-day CV (HR 1.11, 95 % CI 1.01-1.22) and bleeding readmissions (HR 1.39, 95 % CI 1.10-1.76). Among patients with cancer and ACS-CS, revascularization was associated with lower primary outcome (OR 0.54, 95 % CI 0.50-0.58) and 90-day CV readmission (HR 0.68, 95 % CI 0.59-0.77) after PSW. CONCLUSIONS:Among patients with ACS-CS, patients with cancer have similar 90-day death but higher risk of 90-day CV and bleeding readmissions. Additionally, revascularization was associated with improved outcomes among patients with cancer and ACS-CS. Further studies are needed to optimize patient selection for invasive management among patients with cancer.