Transcript Video The Role of TTM in Pulmonary EmbolismProf. Eyal Herzog < Back to Boundaries of Temperature Session 4: Limits The Role of TTM in Pulmonary Embolism Presented by Professor Eyal Herzog our next speaker is coming from Israel. It's Professor I al he is professor of medicine at the Mount Sina Hospital in new york and the director of the department of cardiology in Jerusalem. Israel. Um I have seen that you have published many landmark textbooks on critical care and you have a focus on T. T. M. And pulmonary embolism and that is also the topic of your talk right now today. Welcome professor, thank you. And good morning, ah as many other speaker invited you to their countries, I invite all of you to come to visit Israel. This is not the typical picture you see of Jerusalem, but this is on the mountains of Jerusalem. This is our campus in Hadassah Medical Center. Well, I'm the director of cardiology. Most of the work that I will share with you today when not done in Israel was done in this island. It's called Manhattan. Ah and for the three decades that I lived there and worked there, I created these textbooks that were mentioned earlier. So this is my conflict of interest and I do have a conflict of interest here because these books are still selling and get some income from them. Uh This is the ccO textbook Echo in critical care and the last book just came out six months ago about symbolism and all the slides you're going to see today are from my own books. So there's no real reference to papers. So let's shift to this world of venice thrombosis embolism venice VT is the combined syndrome of DVT and pe pulmonary embolism and is currently the third most frequent acute cardiovascular syndrome globally behind my cardio infarction and stroke. And not surprisingly you see more and more cardiologists now running pulmonary embolism programs around the world. This is the incidence of VT venice Rome by embolism in the United States. This data is from 2021. It's based on earlier data but this is the published data in the United States. Uh It was 1.2 million V. T. E. Cases per year. And out of them 370,000 were pulmonary embolism in one year just for the cardiologists in the room we have only 240,000 S. T. Elevation M. Eyes in the United States, the entire United States. So it's 1.5 times more likely that you're going to develop acute embolism than S. T. Elevation. M. I. And the mortality. Nowadays with three profusion earlier profusion is way higher in puna embolism. So you're going to see very shortly that the entire concept of coronary disease with early re perfusion is now what we do with coronary embolism with early re perfusion. So around the globe. Uh if there are team parrot stands for pulmonary embolism response team, this is a multidisciplinary team that involved in the decision making for the individual patient with coronary embolism. It's bringing together a lot of health care providers from cardiology, pulmonary E. D. Hematology, vascular medicine anesthesia, intensive care cardiac surgery, interventional radiology. I can tell you the team that I have now in my health care system in Jerusalem. We have about 50 members of the team. This team convened in real time when I started in new york, we didn't have WhatsApp system, it was not that mature in the United States so we use regular text messaging and then we moved to the WhatsApp platform and we as you just had acute M. I. Now I had two funds, one Israel one us I get all the P. S. And M. S. Uh huh. And you get real care. I can show you live cases from yesterday of patients with embolism. So the consortium which if you come from the United States you are probably familiar with. The concept was first introduced in 2012. The mass general hospital. Uh There is the consortium was established in 2015. It provides some benchmarks, some guidelines. Uh The estimated to weigh over 100 hospitals now that have powered system, I encourage you wherever you live to build a new program the same way you have an M. I my colleague function team. You should have a team in your hospital. So this is the theme. I'm not going to teach you this small detail that you see of the entire algorithm in one page as a pathway for the manage of patient of cannibalism is the theme of my entire book and each of this concept here is a chapter in the book. So the design. Today, I'm just going to teach you this section here which is hypothermia and cardiac arrest. But the top third, in fact all my algorithms are diagnosis. Then you have to cross through some form of anti calculation. You get the acute management of the patient, you send them home and then you have the chronic management. So in one page here, which you cannot read or understand from this slide, you get the entire management of patient with acute coronary embolism. Now we're going to just zoom into this area over here. So a patient arrives to your health system and you think they have put an embolism, they may have dystonia, chest pain, precinct texas. There is a key question. Every time you start an algorithm there is a key question that makes the difference in the world of puna embolism. The question is hamed, dynamic instability. We talk about definitions key to understand the management to be unstable. In the world of puna embolism you need to have others that you had cardiac arrest or your survive cardiac arrest, you are still getting resuscitation. The second one is defined as obstructive shock and the third one is persistent hypertension. Just for definitions, this is the european definition defines historic blood pressure less than 90 millimeters mercury. Or if you dropped more than 40 millimeter mercury from your baseline, it lasts longer than 15 minutes and it's not related by arrhythmia hyperbole meo sepsis. So this is your key question Because you bridge 90% or 95% of patients embolism belong to patients who are him a dynamically stable. I'm not teaching you this part of the algorithm. I'm teaching you the unstable patient. We are zooming in. So what do you do? You have an unstable patient you are called because there's a cardiac arrest and the diagnosis likely embolism. If you talk about hypothermia will be non chargeable with him. The first thing you do is eco cardiology and not because I used the head of the eco club in new york, because this is the first thing you have to do. Why? It's the same as the concept of coronary disease. If you're unstable and you have put an embolism, the reason you're unstable is the failing right ventricle. So you may not be able to send a patient to a city sweet, you may not be able to send them to any place. So what you do first, you're doing Echo, if you have a normal out of your neck. Oh and I'll show you how you look at it and I'll show you real life cases. You're not in this algorithm. If you are v is abnormal. And I'll show you how we define abnormal RV. You may be able to send the patient to city, if your hospital, everyone available. And if it's feasible, if you can actually bring the patient to a city suite. Obviously if the city is negative, you don't have an embolism. The patients are defined even in the United States, we took over the european definition. It's now defined as high risk embolism. It used to be called in the United States massive embolism were shying away from this terminology. Now you activate your team immediately. There is another way to activate them for stable patients. They all get unfree action happening and then you do your thermodynamic support. Your dynamic support can be as simple as mechanical ventilation or in the tropics support could be as complex as ECMO and other thermodynamic support and these patients likely will go to re perfusion strategy, the same concept as coronary disease. How you reap refuse a patient with an embolism. Either by symbolized or buy em back to me, symbolizes can be systemic by catheter. Em back to me can be systemic or by catheter and eventually the patient will go to cardiac care unit. You don't see the world hypothermia here because now I'm going to incorporate therapeutic hypothermia to this algorithm. There are few cases you can if you just open any problems, you're going to see cases whereas used therapeutic hypothermia in symbolism. But when we put this algorithmic approach, we want it to be very systematic how we recommend doing it. So this is our hypothermia protocol from new york city and I think I'm not repeating what other speakers said before, I just give you a different angle of how I think about brain injury and the problem in cardiac careers that it's extremely difficult to define the severity of the brain injury. So there are five group of patients. I'm going to show you two different slides but the same concept if you think that you have a patient who already found that on the floor for 12 hours in the hospital and someone is calling you now. So it's very clear that he has a very severe pretty tm brain injury and here's very poor outcome and no one will give him T. T. M. On the opposite if you're sitting in the room here and you just faint and you have very mild pretty tm brain injury, you have a very good outcome and no one will consider you for T. T. M. But this is the extreme if you have severe pre T. T. M. Brain injury you will have poor outcome with most of TT M. Therapy. And if you have minimal brain injury you have got outcome with any T. T. M. This is the most of the patients we see especially in the world of porno embolism. They have the level of severity is usually moderate And here and I also use the word those as some other speaker used here, I think that the does between 33 and 36 makes the difference and here is how applied to the base theory. If you're not familiar with the base theory, if you are a cardiologist, this is the basics of stress testing. Why we do stress testing. If you plot any Any degree of likelihood to have a disease or a problem. This is before you apply any therapy and this is after applied therapy for stress testing. I'll go to simple things if you have someone with like 20 years old girl with atypical chest pain and you do negative stress this and this is the graph when you have a negative result and this is a graph, we have a positive result. So, if you have a very pretest likelihood to have a disease, doesn't matter if the stress is negative or positive, the post is likely would stay very low if you have someone who has coronary disease and you do a stress test to him, it's obviously that he will have coronary disease after the stress test. So again, for the extreme here, if you are very likely to have the disease, a negative or positive test will give you the same outcome. So what makes the difference in cardiology? In not in hypothermia, in chest pain. If you have a 50 years old, many of the people in the room here with chest pain, typical chest pain. If you now I put you on a stress test and you have, the negative test. The post test likelihood to have a disease is low positive test will give you highlight the disease. Now let's apply it to therapeutic hypothermia. I'll suggest That the negative will be the graph of 33° and the positive will be the graph of 36°. So if you choose you select your patients in this group, doesn't matter what you do. They will have a good outcome. If you choose this group of patients you have the same outcome. There will be a great outcome if you I have a patient in the middle which is most of my patients, especially my pruno embolism patients. I think the difference will make a whole difference. If I will have a temperature of 33, the post is likely of a brand. You will will be lower. If you have a temperature of 33 you're likely to have a worse outcome. So here is how we plot Now the same concept of unstable premier embolism now with DTM therapy. And this is what appears in my book and I can tell you that this came six months ago I still have to now to make some modification. So we recommended that this part of the reaper fusing strategy and we prefer the capital based re perfusion strategy. I show you some examples you now enter T. T. M. With a temperature between 32 to 36 degrees Celsius to this algorithm. Just that you understand why echo is so critical. There are eight things you want to look in the acute setting of embolism power star along axis. I would just make it simple. I'll show you real life images. You look for a dilated R. V. A. T. Four chamber imaging. You look for dilated LV preservation of the atypical of the apex of the RV. With a kinetic basin meat. It's called McConnell sign. It's likely occurs because the L. V. Is still good. It can pull the epics of the right ventricle but not the rest of the right ventricle. You have this flattening septum critically for all of you in critical care who managed to embolism because if the flattening happening sisterly it means there's a pressure overload. If happening diastolic volume overload happening. Sister land diastolic pressure on overload. And if you have a hypertensive patients and it happened in diastolic don't given fluids because the volume overload already. Just simple picture on echo. Sometimes you need contrast this. You look also in the I. V. C. It's dilated. The sign called 60 60 sign which means that the pressure is less than 60 millimeters mercury. And the artery signal is acceleration time is shorter than 60 milliseconds. You can have a clot in transition. You can do a mode of the Caspian animals you can do to stop. These are basic things we do now in open air embolism. This is from the book show you the apex is actually preserved. The base in the middle of ventricular not moving. This is the 60 60 sign beyond the discussion of this lecture and most of the special. Eventually get a city here you see saddle embolism a large one. So this is the verified algorithm. It's also from the book and you can see that now we apply uh cardiac arrest patient, we do resuscitate the patient. Now we have two groups. Now I want to choose the right dose So how I choose the right dose. Because I do recommend that we're going to start using more and more competitive directed therapy. If you are continuing CCP are two cases for this last month, you are still doing CPR and this is where you try to shy away nowadays from systemic tremble eyes. But if you choose to give systemic tumble is because there's no other choice. Do not go below 3336°C. So the temperature, the dose for this specific group will be 36. However, if you are successful and this is most of the patients are going to see you're going to get them from the field. They will be successful. I do recommend you take them to cut it to director therapy. I do suggest you do give him the dose which is a better dose at 33°C and they will go to the cardiac care unit. Just an example here is a case of pure embolism before cattle Director you see the left side. This is the left side here. Normal coronary perfusion. There's a huge clot obstructive, the right main coronary artery with no flow here in the circulation. After we place this specific cattle here. It's called the different three categories around the world. I want to promote one or another. You can see normally profusion. This is death penalty if you don't touch this patient is dead. And here you have resuming of profusion with this cattle. Ah So let me show you this case study. So this happened two weeks ago, patient is still in the hospital. 56 years old man actively smoking, he has history of cerebral policy, he has residual right side weakness. He's fully functional in his daily life. He worked as a computer scientist for an insurance company in Jerusalem and Israel. He presented to the healthcare system which is our healthcare system is called medical center with three days of wall thinning shortness of breath, right side, chest spin, dry cough and three hours of homeostasis. His heart rate. 113 blood pressure. 1 10/80 for respiratory 18 situation 94 awake. Follow all commands to upon in 1 69 the numbers of different Israel. The normal is 54 Crp was 14. A stable patient with pulmonary embolism. His E. K. G. Typical of an embolism if you have not seen G. There is the sign of S. One and uh Q. Three T. Three. There is a right hand side of your car. There's a right bundle with inverted T wave. This is his echo for thing done on him, patient is stable left ventricle for the people who do not read the left ventricle, sending out the right ventricle, extremely dilated, right ventricle, which is a kinetic to chamber imaging right at you, right ventricle valve, there's a mobile clot appearing here through the hospital of this is what I defined the D shape septum which divide define how you treat a patient. You can see if I freeze damage. I'm not going to do it because of the system here. This D. The letter D. In english should be circle here is happening in sisterly and dastardly meaning there is a pressure overload and volume overload. You don't want to give fluid to this patient. If you become hypertensive and here on this image you can see the right ventricle is very dilated, there's the mobile clutter. This is what you see here. The McConnell sign with preserved typical of the identical base and we are not moving. The left is compressed. You can see the same ethical sparing. We call it on the right side. City, large clot on the left side, large plot on the right, the left was obstructive. He goes, there was per team is activated, very difficult case. One of the most difficult we had for a long time because the patient is a mobile clot in the right side of the heart. He has clear obstructive lesion in his left side but he's completely stable, completely stable. So the decision after a discussion between surgeons and cardiologists and interventional radiologist and the other hematologist involved in this case was to go to cut directed therapy. This is the imaging before therapy, exactly like what you see in the city is a huge clot here. You see the right side. Pay attention to the fusion here, it's okay. No flow. Left side patient is stable. So he was given a cutter to the record thrown back to me and the local thrombosis that those is very low, not what you givin systemic tumble is. It's a three million of the P. A followed infusion of one mg per hour of D. P. A. He went to the CCO six p.m. a few hours later he's becoming to be hemo dynamically unstable. His blood pressure now is 50. Mercury saturation dropped to 85. He goes to p. e. a cardiac arrest, he's dead. They do successful resuscitation for about 20 minutes. And he goes back to the cat Club. We play. We have a very good program. So he goes first on ECMO. Uh and he goes, we put echo in the cutlass but he gets first echo and he gets another imaging go. So this is the echo when he actually becomes to be unstable right ventricle still very dilated, compressing the left ventricle which is very small. This is imaging you see now there's a line here but there's no clot anymore here. Yeah, the effects of the right vehicle is hyper dynamic. The rest is not moving. This is the fourth chamber imaging. The only difference from the prior image and this image is is not clot anymore, apex still moving here, identical is compressed, huge right side of the heart. So he goes back to the custom. Look, the re perfusion strategy on the left works very well but the clot went and now is filling the right side so there is no flow to the right side. This is why he had called the quest. So he gets another therapy. So target temperature minute in this case was relatively easy because the patient is on ECMO. It's very easy to put therapeutic hypothermia. On ECMO. The decision was very difficult what temperature, what does to choose but because he was given twice from ballistics via Catheter directed therapy we choose the dose of 36° And he was very slowly, as other speakers said earlier, it was re warmed to 37° Day six Post ECMO. He improved him or dynamically we do an echo because we have to know how to remove someone from from ECMO. We use echo for this look complete recovery of the right ventricle. Left ventricle was normal earlier was compressed. It's not compressed. RV comes back. Four chamber imaging. L. A L. V R E L V, normal LV function. Sub costal imaging the LVs here looks great. So we reduced the flow from the ECMO and we repeat echo even in low flow and mow we see normal preservation of the right ventricle. So we know we can actually remove the patient from ECMO. And this is what I preparing the slides when I asked to give the slides that he was improved neurologically. But I can tell you that I just made a phone call and he's actually not doing that well from brand status. So he's still alive. He's still in the hospital but he's not doing that well. I just had an active case. I want to share with you how difficult this decision and how this world is changing. I think I will stop here. My time is. So it's all about collaboration because the teams that took care of these patients in all about 50 physicians, including 12 different departments from our health system. So it's all about working together to put to try to save this patient life. Thank you Created by
