Penn Medicine is home to a system-wide comprehensive Care Program for patients with acute and chronic pulmonary thromboembolic conditions.
Drawing upon the expertise of a multi-specialty team of physicians, the Program comprises three aspects of care: chronic thromboembolic pulmonary hypertension (CTEPH); the Pulmonary Embolism Response Team (PERT), and the outpatient programs associated with the Penn Pulmonary Embolism Clinics.
Among the concentrations of the Program are efforts aimed at specific conditions (including CTEPH and acute pulmonary thromboembolic disease) and aspects of management, including ongoing outpatient care for patients with acute and chronic pulmonary embolism. Each of these areas is the focus of dedicated research and treatment programs at Penn Medicine, and each has common objectives, including prompt evaluation, establishment of a treatment strategy, risk stratification, and guidance in long-term care.
Management of CTEPH at Penn Medicine
Resulting from prior pulmonary embolism (PE), CTEPH manifests as ongoing pulmonary vascular obstruction and remodeling, often leading to shortness of breath and right heart failure. At Penn Medicine, patients with CTEPH receive supportive and targeted medical and surgical therapies to diagnose and address the etiology, symptoms, and long-term sequelae of the condition. Medical therapies include long term anticoagulation and pulmonary vasodilators; surgical options include balloon pulmonary angioplasty and pulmonary thromboendarterectomy, both of which are available at only a handful of medical centers nationwide.
Pulmonary Embolism Response Team (PERT)
PE is a medical emergency that may lead to pulmonary hypertension and life-threatening damage to the heart in the absence of timely intervention.
The PERT at Penn Medicine manages the needs of patients with all severities of PE, including patients who have had recent surgery, stroke, or major bleeding that traditionally have limited treatment options. Comprising a core group of specialists, each of whom contributes his or her expertise to consultation, evaluation, and treatment, the PERT establishes risk stratification protocols, improves access to advanced therapy, streamlines patient care, manages the comorbidities of PE, and formulates long-term post-discharge planning with patients' primary providers.
Treatment
PERT members employ a variety of percutaneous devices to address the clotting of PE, including low-dose catheter directed thrombolysis and percutaneous embolectomy for those at high risk for anticoagulation or thrombolytic therapy. Surgical embolectomy may be performed in appropriate patients. For patients in shock, hybrid approaches to therapy involving extracorporeal membrane oxygenation (ECMO) and catheter-based treatments are used routinely at Penn.
Outpatient Care at the Penn Pulmonary Embolism Clinic
The Penn Pulmonary Embolism Clinics provide multidisciplinary care for patients recovering from acute pulmonary embolism or continuing issues from CTEPH. Staffed by cardiovascular and pulmonary disease specialists, the Clinics offer advanced cardiovascular and pulmonary diagnostics, and ongoing therapy as needed, including access to cardiac and pulmonary rehabilitation. The care program is unique in coordinating transition of care from the inpatient to outpatient setting with short term follow up to reduce lapses in anticoagulation and address any complications from the inpatient stay. Patients are followed closely to prevent and detect any long-term complications from acute PE including CTEPH.
Clinical Research | Recruiting Clinical Trials
As a leading resource for clinical research in pulmonary medicine, including pulmonary embolism, CTEPH, and pulmonary artery hypertension, Penn Medicine offers access to clinical trials involving advanced therapies and innovative technologies for acute and chronic PE.
Current enrolling pulmonary clinical studies at Penn Medicine include:
Pulmonary Embolism:
- PE-TRACT (NCT05591118): An assessor-blinded RCT comparing catheter-directed therapy and anticoagulation with anticoagulation alone in 500 patients with acute intermediate risk PE; the primary endpoint is functional outcomes at 3 months and 1 year.
- PEERLESS II (NCT06055920): A prospective, multicenter, RCT of the catheter based embolectomy device "FlowTriever" vs. anticoagulation alone in pulmonary embolism.
- ENGULF (NCT05597891): Single-arm evaluation of safety and clinical feasibility of a novel catheter thrombectomy device for the treatment of pulmonary embolism.
CTEPH:
- PHAR Registry (NCT04071327): The Pulmonary Hypertension Association (PHA) registry tracking patients with chronic thromboembolic pulmonary hypertension (CTEPH) and pulmonary arterial hypertension (PAH).
- ACTIPH (Physical Activity in Pulmonary Arterial Hypertension): using a novel wearable biosensor to determine whether physical activity patterns are associated with improved outcomes and health-related quality of life in patients with CTEPH and PAH.
Contacting the Penn Comprehensive Pulmonary Thromboembolism Program
- To schedule a new outpatient appointment, please call 215-662-8766 and ask to be scheduled in the Pulmonary Embolism Clinic. Clinic sites include the Perelman Center and Penn Medicine University City.
- For acute PE-related outside hospital transfers to HUP or PPMC, please call the Penn Medicine Transfer Center at (877) 937-7366 and ask to speak with the PERT attending on call. For patients with known CTEPH requiring inpatient transfer, please ask to speak with the HUP Pulmonary Hypertension attending on call.
Case Study
Figure 1: Pulmonary angiogram of the lungs demonstrating areas of chronic thrombus (arrows) leading to vessel narrowing and reduced blood flow.
Ms. R, a 36-year-old woman with a history of recurrent pulmonary embolism, presented to the emergency room at her community hospital with syncope in the setting of several months of dyspnea. A CT scan in the ER revealed extensive large bilateral pulmonary emboli (Figure 1) with RV strain and right ventricular dysfunction on echocardiogram, and severely elevated pulmonary artery pressures concerning for acute-on-chronic PE.
Soon afterward, Ms. R was transferred to Penn Medicine, and a consult was placed to the pulmonary response team (PERT), which met to consider the risks and benefits of the options for treatment, which included systemic t-PA, catheter directed t-PA, surgical embolectomy, and percutaneous embolectomy. Given her severe symptoms and signs of both acute and chronic PE, Ms. R had a right heart catheterization to measure her pulmonary artery pressures, which demonstrated severe pulmonary hypertension. Following treatment with catheter-directed thrombolysis, Ms. R saw improvement in both her symptoms and right ventricular dysfunction on echocardiogram.
Three months after discharge, however, Ms. R was seen in the Penn Pulmonary Embolism Clinic, where, despite catheter directed thrombolysis and prolonged effective anticoagulation, she showed persistent symptoms of shortness of breath, ongoing right ventricular dysfunction, and elevated pulmonary artery pressures on echocardiogram.
A repeat right heart catheterization and diagnostic digital subtraction pulmonary angiography were performed, and found severe pulmonary hypertension, large bilateral perfusion defects and findings typical of proximal chronic thromboembolic disease.
After review by Penn Medicine's multidisciplinary CTEPH team, Ms. R then received pulmonary thromboendarterectomy surgery, and saw resolution of her pulmonary hypertension and symptoms of shortness of breath.
About the Penn Pulmonary Thromboembolism Program
At Penn Medicine, the care of patients with acute and chronic thromboembolic disease is a comprehensive, system-wide effort involving specialists in pulmonary medicine, interventional cardiology, diagnostic radiology, hematology, cardiovascular surgery and rehabilitation services.