PE for Surgeons: Be Active Participants in Team-Based Care, Experts Urge

NEW ORLEANS, LA—Surgeons can play a key role in the movement toward a multidisciplinary approach to caring for patients with pulmonary embolism (PE), an area in which these physicians are not always involved, experts urged during a dedicated session at the 2020 meeting of the Society of Thoracic Surgeons (STS).

Pulmonary embolism response teams (PERTs), a term first coined in 2012 by physicians at Massachusetts General Hospital in Boston, have been coalescing as a more cohesive way to manage patients who present with PE. In 2015, the PERT Consortium was created to facilitate communication among clinicians and develop best practices.

There is general consensus that the rapid-response model is having an effect. Still, data in the field are only beginning to emerge and processes differ among institutions.

David Joyce, MD (Medical College of Wisconsin, Milwaukee), who co-chaired the STS session, said its focus highlights the merging of two ongoing movements within the field of cardiothoracic surgery.

“One is that people are increasingly recognizing the importance of a multidisciplinary team,” he told TCTMD. “We've also seen just rapid advances in technology with all of the different options we have for treating this condition. When you put those things together—the crowd wisdom that we get from the PERT team as well as the multiple options that we have now for customizing our approach to each unique patient—I think we're going to see some really big changes in the outcomes for this disease, which will be really exciting.”

Addressing the ‘Treatment Gap’

Kenneth Rosenfield, MD (Massachusetts General Hospital), one of the physicians who spearheaded the PERT movement, presented how his hospital came to create its protocol.

“I would call PE an international crisis—it’s got a high incidence, it's ubiquitous, it has major morbidity and mortality in long-term sequelae, and it's underrecognized both by clinicians and the public,” said Rosenfield, immediate past president of the PERT Consortium. “It’s just a thing that people don’t think about. And yet, in spite of this incredible impact, the public awareness globally is terrible.”

He highlighted the “huge treatment gap” in PE: fewer than 5% of patients receive advanced therapy. “Why is that? There’s an inability for our systems to respond rapidly,” Rosenfield said. “We often fail to recognize potential benefit and that's because we don't have adequate data . . . to prove that [benefit].”

The first major difficulty in treating PE is for the practitioner to recognize it, Rosenfield explained. “That’s often very challenging because it’s a great masquerader.” Next, the patient’s risk needs to be calculated and assessed against a wide variety of possible treatments which lack an evidence base. “Do you use thrombolytic therapy? Half dose? Full dose? Catheter-directed? Pharmacomechanical? Do you take them to the operating room and extract the clot or do you do thromboaspiration with any of these new devices that are available? And when do you need to use ECMO or RV support?”

Given that PE patients can present anywhere from the orthopedic ward to the emergency department to the postcardiac surgical floor, Rosenfield said, systems have widely varied within hospitals for how they are assessed and ultimately treated. In an effort to bring consistency to care, Mass General physicians created the first PERT: an electronic meeting that could be activated by any physician, with the phone number advertised on posters around the hospital.

“The first weekend we put the poster up, there were seven calls and I said to myself, ‘What the heck was happening with these patients before?’” Rosenfield remembered. “They were all being treated by whatever floor, whatever practitioner, without a real knowledge base, and these people are really looking for help as to how to manage these patients with PE.”

Since then, he said, the success of their PERT has increased communication and led to easier transitioning of patients, more consistency in management, and fewer unnecessary variations in care. “We believe we’re making appropriate decisions about interventions and when not to intervene, and our follow-up is a hundred times better,” Rosenfield said. “We're increasing our education and awareness of our colleagues in the community and the hospital.”

Looking forward, Rosenfield envisions a time when PE is no longer the challenge it is today. "I think that’s within our reach at some point in time, certainly to greatly reduce the incidence of this thing. The keys are collaborative spirit, inclusiveness, and working together, so I think PERT will establish a new standard of care,” he advised.

Encouraging Surgeon Involvement

In discussion following Rosenfield’s presentation, audience member Lyle Joyce, MD, PhD (Medical College of Wisconsin, Milwaukee), said although he sees PERT calls as a positive development, one major problem for the cardiac surgeon is that they can be left out of the process altogether or at least over the long term.

“If the group decides that they're going to go onto thrombolytics or another nonsurgical direction, I don’t hear about that patient again. It seems like even within our own center, if we had monthly, quarterly, even every 6-month reviews of what treatment was given for this submassive [PE] patient and what the outcomes were, we might improve our care even more,” he suggested.

Rosenfield told TCTMD he thought this was a great idea. “I wrote myself an email saying that we need to actually establish this,” he said. “One of the things we can do in addition to this database, which gives regular feedback to sites about how they're doing as a center compared to the rest of the Consortium, is provide them a data form [that] they can use in-house to [provide] feedback for their own team members and their own institutional quality officers [about] how they're doing.”

Surgeons in general “are critically important to this whole field,” Rosenfield continued. “Without the surgeons, we're missing a big component, so any place that doesn't have the input of surgeons or the surgical perspective is really missing an important component of treating PE care. I'm thrilled that they had this session here for that reason and also to spread the message about PERT.”

Joyce, the co-moderator, noted that it can be frustrating as a surgeon to be on several PERT calls but only really needed in one or two. However, he urged surgeons to keep participating.

Only once the institutional culture has changed to where the PERT protocol is widely accepted and used will there be “a role for being a little more refined about how you assess that disease up front,” Joyce said. “Probably as you become more sophisticated [and case volume rises] it makes sense that the next phase of things is that you get somebody on the front end that screens things and says, ‘Okay, maybe just for massive [PE] we'll call the surgeon and for submassive it'll be a different group of people.’”

He encouraged surgeons to remember that they have much to offer, “whether it's surgical embolectomy or even just having a voice when it comes to the decision about lytics, because once we give those lytics the bridge has been burned. Being involved in that conversation up front is really important I think.”

Joyce also brought up another key point: the need for better patient follow-up. As cardiothoracic surgeons, often “we're in the mode of sort of we fix the problem and we send them on their way,” he said, mentioning A-fib ablation as an example.

With PE, on the other hand, “we really need to continue following these people, particularly with respect to the risk of [chronic thromboembolic pulmonary hypertension]. If we can sort of get a little more feedback and follow-up after we've managed their condition, I think we'll be able to make even better decisions and refine some of those tough questions,” he said.