Imagine being a physician dedicated to preserving life and realizing a patient will probably die because there is not an acceptable treatment for what ails that patient. That dilemma is exactly what confronted cardiologist Stanley Bleich and cardiovascular thoracic surgeon Tod Engelhardt exactly two years ago. The patient had arrived at East Jefferson General Hospital in cardiogenic shock with chest pain and severe shortness of breath two weeks following coronary artery bypass surgery. He was diagnosed with a massive pulmonary embolism (PE) that extended into his right ventricle and right atrium.
Dr. Engelhardt describes the diagnosis of PE as "the most dreaded complication of venous thromboembolic disease a person can have." Acute PE refers to obstruction of the pulmonary artery or one of its branches. It can be clinically described as acute or chronic and massive or submassive. It is a catastrophic entity that frequently results in acute right ventricular failure and death. When death does occur, it is often within 1 to 2 hours of a patient suffering a cardiac event. It is that time element that presents the greatest hurdle in saving these lives.
The traditional treatment of massive pulmonary embolism is anticoagulation with heparin and possibly systemic Tissue Plasminogen Activator (TPA) or surgical extraction of the clot. This patient had just had major heart surgery, and both of these options were considered to be too high of a risk. Dr. Bleich consulted Dr. Engelhardt, who had been working with an ultrasonic catheter in the treatment of deep vein thrombosis and acute arterial occlusion. The catheter had never been used to treat such an extensive PE with extension into the heart. Dr. Engelhardt suggested that the catheter could be placed directly into the clot, and a much lower and safer dose of TPA could be delivered in order to dissolve the clot, lessening the patient’s risk of catastrophic bleeding. Once they decided the patient had no other option, it was only a matter of minutes before the catheter was in place and the lifesaving drug was being administered. The procedure was done in the Cardiac Cath Lab with the use of state-of-the-art X-ray equipment. The patient’s symptoms began to improve within minutes, and he became very stable two hours later.
The above patient had a massive PE and was very close to dying of this most dreaded complication of venous thromboembolic disease. When patients die of a PE, it is usually due to right heart failure. Patients with submassive PE have a normal blood pressure and are usually short of breath, but they also demonstrate an enlarged right heart. These patients are also treated with the ultrasound-assisted thrombolytic catheter. Doing so presents transition into the massive category and prevents development of pulmonary hypertension and right heart failure.
Imagine the elation of not only saving a life, but doing so in a manner that you are not sure anyone else had ever tried. Dr. Engelhardt informed the company that makes the vibrating catheter of his success. They were thrilled and immediately began looking into whether or not any standard of care had been developed. If this is indeed a new standard of care, this would change the treatment protocols for PE cases and perhaps save many of the 600,000 lives that are lost each year to cases of massive pulmonary embolism.
At the time of this writing, Dr. Engelhardt has performed this procedure on 32 patients. When asked what the odds of living were for these patients without this new procedure, he hesitates, then in a simple measured tone, says, “Not very good, not good at all.” Word spreads quickly in medical circles when more than a half million potential lives could be saved. In the past few months, Dr. Engelhardt has been asked to provide talks or description of this procedure to physicians throughout the United States, Europe and India. The entire process has been somewhat humbling to Dr. Engelhardt. At East Jefferson General Hospital, we have demonstrated excellent cardiac care, but this demonstrates that we have the surgeons, technology, technicians, nurses, support staff, and also the support of our administration to continue improving and doing what is in the best interest of our patients.
A Patient Cheats Family History
In the winter of 2010, Joe Leblanc had suffered a massive heart attack and passed away. Now, almost a year later, Joe's wife Gloria had undergone a surgical procedure and in the course of her care, had been identified as having a pulmonary embolism. The same thing had killed her husband. Now the clock was literally ticking on how soon they could treat her to prevent history from repeating itself horribly within this one family.
Gloria's physician consulted with Dr. Engelhardt to determine if Gloria was a good candidate for his new catheter procedure. Dr. Engelhardt remembers Gloria as being "ideally suited for this." Once that determination was made, within a matter of minutes, a Cath Lab Suite had been set up with the special EKOS Catheter Dr. Engelhardt would need. His care team had been assembled and Gloria was being transported into the Cath Lab for her procedure. Dr. Engelhardt put his hand on hers and assured her that she was going to be fine. Only a few moments later, on the large video monitor across the surgery table from Dr. Engelhardt, he could see that the catheter was in place and he was introducing the clot busting drug that would save Gloria’s life. The entire process from the time she was brought into the suite until she was being transported to recovery, had taken less than 45 minutes. Immediately, Dr. Engelhardt knew the procedure had been a success. He was able to go out to the waiting area and tell Gloria's family that she had come through the procedure with great success and she was going to be fine.
To Dr. Engelhardt, Gloria represents the best aspect of what he does for a living. "To be able to see these patients a few weeks after they were in such dire condition and see them come into my office walking and smiling and so full of life. That is the best part of what we do."
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