PERT Podcast A VTE Discussion With a Focus on ESC Guidelines and Treatment Duration

The PERT consortium invites you to listen to a podcast moderated by Geoff Barnes, MD, and joined by Greg Piazza, MD, Rachel Rosovsky, MD, and George Davis, PharmD, as they discuss extended VTE treatment and the ESC 2019 guidelines.

These podcasts were developed by the featured Pulmonary Embolism Response Team (PERT) Consortium speakers through a sponsorship from Janssen Pharmaceuticals, Inc. Doctors are also paid consultants of Janssen Pharmaceuticals, Inc.

© Janssen Pharmaceuticals, Inc. June 2021 cp-173153v3

PERT Podcast Management Pathways for PE

The PERT consortium invites you to listen to a podcast moderated by Emily Gundert, MD, and joined by Geno Merli, MD, and Jeff Kline, MD, as they discuss the management of pathways for the treatment and management of pulmonary embolism.

These podcasts were developed by the featured Pulmonary Embolism Response Team (PERT) Consortium speakers through a sponsorship from Janssen Pharmaceuticals, Inc.

© Janssen Pharmaceuticals, Inc. June 2021 cp-173153v3

PERT Podcast The PERT Approach to the Treatment and Management of Pulmonary Embolism

The PERT consortium invites you to listen to a podcast moderated by Immediate Past President of PERT Consortium, Richard Channick, MD, and joined by Chris Kabrhel, MD, Kenneth Rosenfield, MD, Brent Keeling, MD, Robert Lookstein, MD MHCDL, and Christina Fanola, MD as they discuss the PERT approach to PE management.

These podcasts were developed by the featured Pulmonary Embolism Response Team (PERT) Consortium speakers through a sponsorship from Janssen Pharmaceuticals, Inc. Some Doctors are also paid consultants of Janssen Pharmaceuticals, Inc.

© Janssen Pharmaceuticals, Inc. June 2021 cp-173153v3

The PERT Consortium invites you to listen to a podcast moderated by past immediate president of PERT Consortium Victor Tapson, MD, and joined by Alex Spyropoulos, MD, as they discuss clinical trial data on early hospital discharge of patients with a low-risk PE, risk stratification tools, as well as recent guideline recommendations.

The PERT Consortium invites you to listen to a podcast moderated by past immediate president of PERT Consortium Victor Tapson, MD, and joined by Alex Spyropoulos, MD, as they discuss dedicated DOAC trials that evaluated the treatment of pulmonary embolism.

PERT Webinar - Cases Over Cocktails Hear How Experts Are Treating Challenging PE Cases

The PERT Consortium invites you to join our next webinar, Cases over Cocktails, with our current and past presidents, Richard Channick, MD and Victor Tapson, MD, FCCP, FRCP and moderated by PERTs' first president, Kenneth Rosenfield, MD, MHCDS, FACC, MSCAI. Hear how experts are treating challenging PE cases.

PERT Webinar - PE And the Covid Pandemic Expert Opinions from European and US Hot Spots The PERT Consortium invites you to join another ground breaking webinar with our colleagues from Spain, the Netherlands, and New York- David Jimenez, MD, Erik Klok, MD, and Matt Langston, MD. Learn how international and U.S. clinicians face the challenges surrounding PE and the COVID-19 Pandemic. This will be a 2 hour webinar-including case presentations, and Q & A. Our expert panelists include: James Horowitz, MD, Brent Keeling, MD, Robert Lookstein, MD, MHCDL, Seth Sokol, MD, Victor Tapson, MD.

PERT Webinar - COVID-19 and Pulmonary Embolism Perspectives from China and the United States The PERT Consortium invites you to join this ground breaking webinar with Charles Grodzin, MD, and our Chinese colleague, Shaoping Nie, MD, PhD, FESC, FSCAI to learn about how US and international clinicians are facing the challenges surrounding PE care in the COVID-19 epidemic. This will be a 2 hour webinar-including a case presentation, and time for Q&A. Our expert panelists include: Geoffrey Barnes, MD, MSC, James Horowitz, MD, Andrew J.P. Klein, MD, FACC, FSCAI, Rachel Rosovsky, MD, MPH and Vic Tapson, MD.

Episode 5: Dr. Rosovsky interviews Dr. Robert Lookstein about the new PERT Consortium Database!!

Dr. Lookstein is a Professor of Radiology and Surgery at the Icahn School of Medicine at Mount Sinai.

Dr. Rosovsky is the Director of Thrombosis Research within the Division of Hematology at Mass General Hospital.

Episode 4: Dr. Rosenfield interviews Dr. Richard Channick on Post PE care!

Dr Channick is the current PERT Consortium president and is the Director of the Acute and Chronic Thromboembolic Disease Program within the David Geffen School of Medicine at UCLA.

Dr. Rosenfield is Section Head of Vascular Medicine and Intervention at Mass General Hospital and past PERT president and founder.

What happens after a PE?

• Following acute pulmonary embolism some patients do not return to their baseline and may suffer from what is called post PE syndrome.
• Some of these unfortunate patients develop chronic thromboembolic disease or chronic thromboembolic pulmonary hypertension

Follow Up Clinic

• In clinic it's important to assess if patients have returned to their baseline of physical acitivity. If the answer is no, then go for objective testing
• First step may be getting a follow-up echocardiogram or repeat imaging
• CTA is extremely helpful for acute pulmonary embolism. CTA is less revealing for chronic pulmonary embolism. VQ scan is the most sensitive test for the chronic pulmonary embolism. If VQ scan is normal 8 to 10 weeks following acute PE rhythm you do not have any chronic pulmonary embolism
• Following an abnormal VQ scan next steps should be --> evaluated for CTED or CTEPH.

Define chronic thromboembolic pulmonary hypertension and its characteristics?

• CTED or CTEPH is a scar tissue forming in pulmonary vessels is not an acute clot. à higher degree of such vascular obstruction will lead to increase in PVR and eventually PHTN and RV dysfunction.
• CTED or CTEPH has distinct appearance on imaging: Chronic clot may have appearance of fibrous bands, webs or bands. Appearance is quite different than acute clot.
• Extremely high pulmonary artery pressure of about 80 or 90 millimeters of Hg suggest chronic right ventricular pressure overload.
• Bronchial collaterals on CTA may suggest a chronic process.

Acute Vs Chronic Clot on Imaging:

• Acute clot will have a central occlusive appearance.
• Sometimes it is hard to differentiate. If patient has not been anticoagulated in the past you anticoagulate and do a follow-up in 8 to 10 weeks.
• Signs of RV hypertrophy on the echocardiogram also suggests a chronic process

Treatment of chronic thromboembolic pulmonary hypertension

• First-line of treatment is surgical. [It is complicated cardiac surgery that involves expert surgical team. It involves cardiopulmonary bypass, deep hypothermic arrest and needs and expertise.]
• Balloon pulmonary angioplasty growing evidence.
• RIOCIGUAT is the only approved drug for CTEPH. Macitentan has been studied but not approved. PDE inhibitors also have been tried
• Upfront medical therapy should not delay the referral for the patients who potentially are surgical candidates.

Types of chronic thromboembolic pulmonary disease and surgical classification

• Four levels depend on whether the disease starts
• If the disease starts proximally it is easier for the surgeon to dissect. It depends where the chronic clots are involving the pulmonary vasculature.

Level 1 disease: Proximal disease Level 2 disease: Lobar disease Level 3 disease segmental disease Level 4 disease sub-segmental disease

Basics Concepts of Balloon Pulmonary Angioplasty (BPA)

• It involves dilating the narrowed pulmonary segments and improve with the primary pulmonary perfusion and reducing the pulmonary hypertension.
• First step is to do the pulmonary angiogram. Then match the perfusion defects with the VQ scan. Work as a team.
• Goal is not to over distend the pulmonary vasculature. Goal is just to break up the scar or the fibrous tissue and increase distal perfusion. Vascular stenting is not performed usually.
• BPA is a staged procedure. The session can last anywhere between 2-3 to 12-13 sessions.
• Each session is 2 to 3 hours involves fair amount of radiation and the contrast.
• Pulmonary hemorrhage is a very serious complication; BPA has a learning curve.