Ep. 38 Advances in PE Treatment Guidelines with Dr. Jay Giri and Dr. Trevor Cummings

Ep. 38 Advances in PE Treatment Guidelines with Dr. Jay Giri and Dr. Trevor Cummings

Will new PE guidelines redefine risk and therapy in pulmonary embolism (PE) care? In this episode of the BackTable podcast, host Dr. Michael Barraza is joined by interventional cardiologist Dr. Jay Giri and emergency physician Dr. Trevor Cummings to break down the latest changes in PE management. They discuss how multidisciplinary pulmonary embolism response teams (PERT) are implementing these guidelines at their institutions, the introduction of a more nuanced A-E risk stratification system, and the challenges of enrolling experienced centers into clinical trials as device innovation accelerates. --- Get the BackTable app https://www.backtable.com/app --- This podcast is supported by Inari Medical https://www.inarimedical.com/flowtriever-system --- Timestamps 00:00 - Introduction 01:24 - Building a PERT Team 04:59 - Trials Shaping PE Care 10:20 - Why New Guidelines Now 14:06 - New Risk Categories Explained 19:51 - Applying Guidelines Locally 23:34 - What Is C1 Risk 27:52 - New D Category Explained 30:33 - Evidence for Aggressive Therapy 33:31 - How PERT Teams Communicate 38:22 - Upcoming PE Trials Pipeline 43:42 - Program Growth and High Risk Trials 45:46 - Closing Remarks --- More about this episode The conversation highlights the growth of catheter-directed lysis and mechanical thrombectomy, the rationale and practical impact of the new Category D for incipient cardiopulmonary failure (including normotensive shock), and the incorporation of PESI, sPESI, and Hestia for risk assessment. Additional topics include decision-making for low-risk patients, lactate and biomarkers for identifying higher-risk cases, communication strategies within PERT teams, AI-enabled risk stratification, and a preview of upcoming trials (PEITHO, PRAGUE-26, PEERLESS-2, PE-TRACT, and PERSEVERE) that are set to further transform PE care. --- Resources Management of Massive and Submassive Pulmonary Embolism, Iliofemoral Deep Vein Thrombosis, and Chronic Thromboembolic Pulmonary Hypertension: A Scientific Statement From the American Heart Association https://pubmed.ncbi.nlm.nih.gov/21422387/ Surgical Management and Mechanical Circulatory Support in High-Risk Pulmonary Embolisms: Historical Context, Current Status, and Future Directions: A Scientific Statement From the American Heart Association https://pubmed.ncbi.nlm.nih.gov/36688837/ Interventional Therapies for Acute Pulmonary Embolism: Current Status and Principles for the Development of Novel Evidence: A Scientific Statement From the American Heart Association https://pubmed.ncbi.nlm.nih.gov/31585051/ Ultrasound-Facilitated, Catheter-Directed Fibrinolysis for Acute Pulmonary Embolism https://pubmed.ncbi.nlm.nih.gov/41910345/ PEERLESS II: A Randomized Controlled Trial of Large-Bore Thrombectomy Versus Anticoagulation in Intermediate-Risk Pulmonary Embolism https://pubmed.ncbi.nlm.nih.gov/39132600/ Rationale and design of the PE-TRACT trial: A multicenter randomized trial to evaluate catheter-directed therapy for the treatment of intermediate-risk pulmonary embolism https://pubmed.ncbi.nlm.nih.gov/39638275/ Reduced-Dose Intravenous Thrombolysis for Acute Intermediate–High-risk Pulmonary Embolism: Rationale and Design of the Pulmonary Embolism International THrOmbolysis (PEITHO)-3 trial https://pubmed.ncbi.nlm.nih.gov/34560806/ Design and rationale of the PERSEVERE study: a randomized controlled trial of large-bore mechanical thrombectomy versus the standard of care for high-risk pulmonary embolism https://pubmed.ncbi.nlm.nih.gov/41453591/ Design and rationale of PRAGUE-26: a multicentre, randomised trial of catheter-directed thrombolysis for intermediate-high risk acute pulmonary embolism https://pubmed.ncbi.nlm.nih.gov/40464677/ --- BackTable Cardiology is the go-to podcast for interventional cardiologists, cardiac surgeons, and other healthcare professionals that manage cardiovascular conditions. Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty. ► https://www.backtable.com/app

Ep. 37 Breaking Down the New Pulmonary Embolism Guidelines with Dr. Sanjum Sethi

Are the latest pulmonary embolism guidelines changing how you risk-stratify and intervene on acute PE? In this episode of BackTable Cardiology, host Dr. Hady Lichaa interviews Dr. Sanjum Sethi of Columbia University Medical Center about the evolving management of pulmonary embolism (PE) and the major updates reflected in the newest guidelines. They review the new A–E risk classification system, key updates to systemic thrombolysis recommendations, and the expanding role of catheter-based therapies as randomized evidence emerges, highlighting how these changes are shaping PERT protocols, influencing clinical decision-making, and affecting patient outcomes. --- Get the BackTable app https://www.backtable.com/app --- Timestamps 00:00 - Introduction 01:40 - Major Guideline Changes 13:26 - Essential Components of PERT Calls 16:38 - Assessing Clot Burden 24:32 - When To Prioritize Surgical Management 30:15 - Importance of RV Function 31:26 - Heparin Versus LMWH 37:58 - TPA Dosing 43:42 - Thrombectomy Devices And Guidelines 50:19 - Future Technology --- More about this episode The doctors discuss key practice updates, including the new Class I recommendation to incorporate lactate into shock assessment and the downgrade of systemic thrombolysis for highest-risk PE patients while highlighting the expanding evidence and indications for catheter-based therapies. Dr. Sethi outlines the essential clinical data to gather during PERT calls, including vital signs, RV function, biomarkers, and patient goals, and explains why relying solely on CT thrombus burden can be misleading. They discuss the importance of echocardiography for detecting findings like PFO or clot-in-transit and provide guidance on when to consider surgical intervention or ECMO, how to choose between heparin and LMWH, and the nuanced decision-making behind selecting catheter-directed thrombolysis versus mechanical thrombectomy. --- Resources Dr. Hady Lichaa’s Provider Profile https://healthcare.ascension.org/find-care/provider/1336267533/hady-lichaa Dr. Sanjum Sethi’s Provider Profile https://www.columbiacardiology.org/profile/sanjum-s-sethi-md-mph 2026 AHA/ACC/ACCP/ACEP/CHEST/SCAI/SHM/SIR/SVM/SVN Guideline for the Evaluation and Management of Acute Pulmonary Embolism in Adults https://www.ahajournals.org/doi/10.1161/CIR.0000000000001415?utm_campaign=sciencenews25-26&utm_source=science-news&utm_medium=phd-link&utm_content=phd-2-19-26 Pharmacomechanical Catheter-Directed Thrombolysis With the Bashir Endovascular Catheter for Acute Pulmonary Embolism: The RESCUE Study https://www.jacc.org/doi/10.1016/j.jcin.2022.09.011 --- BackTable Cardiology is the go-to podcast for interventional cardiologists, cardiac surgeons, and other healthcare professionals that manage cardiovascular conditions. Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty. ► https://www.backtable.com/app

Ep. 36 Understanding CTEPH Diagnostic & Interventional Techniques with Dr. Vladimir Lakhter

Could persistent dyspnea after a “resolved” PE be more than just deconditioning or diastolic dysfunction? In this episode of BackTable Cardiology, Dr. Hady Lichaa hosts interventional cardiologist and vascular medicine specialist Dr. Vladimir Lakhter, to discuss the diagnosis and management of CTEPH and chronic thromboembolic disease (CTED). They review the prevalence of CTEPH following pulmonary embolism, common delays in diagnosis, and why symptoms such as dyspnea are often misattributed to conditions like diastolic dysfunction. --- Get the BackTable app https://www.backtable.com/app --- Timestamps 00:00 - Introduction 02:40 - Defining CTEPH 07:00 - Diagnostics for Detection 12:02 - Treatment Considerations 16:08 - Anatomy Challenges 22:03 - Device Options and Techniques 29:40 - BPA Procedure 39:50 - Interpreting Angiographic Appearance of CTEPH 48:10 - BPA Challenges and Risks 52:06 - Diuretics 55:10 - Post BPA Diagnostics and Complications 01:02:42 - Treatment Endpoints 01:06:10 - Continuing Education and Expert Resources 01:08:41 - Closing Thoughts --- More about this episode Dr. Lakhter outlines a practical diagnostic workup, emphasizing the Ventilation-Perfusion (V/Q) scan as the key screening test, supplemented by thin-cut CT pulmonary angiography and transthoracic echocardiography (TTE). He then explains how treatment decisions are made within a multidisciplinary framework, balancing medical therapy, surgical pulmonary endarterectomy (the curative gold standard for surgically accessible disease), and balloon pulmonary angioplasty (BPA) for patients with distal disease, residual pulmonary hypertension after surgery, or those who are not surgical candidates. Drs. Lichaa and Lakhter dive into a detailed procedural overview of BPA, including pulmonary artery anatomy resources, pulmonary angiography technique, access and equipment selection, lesion classification, and intraprocedural assessment using pressure wires and venous return patterns. Dr. Lakhter shares practical strategies to minimize complications, including undersized balloon sizing to reduce reperfusion pulmonary edema, routine post-procedure diuresis, and management of complications such as pulmonary artery injury and tamponade using Gelfoam, coils, and, in rare cases, vascular plugs. They finish the conversation with a closer look at typical BPA staging and treatment endpoints. --- Resources Dr. Hady Lichaa’s Provider Profile https://healthcare.ascension.org/find-care/provider/1336267533/hady-lichaa Dr. Vladimir Lakhter’s Provider Profile https://www.templehealth.org/doctors/vladimir-lakhter Balloon Pulmonary Angioplasty (BPA) for Treatment of Chronic Thromboembolic Pulmonary Hypertension (CTEPH) https://pubmed.ncbi.nlm.nih.gov/11136677/ --- BackTable Cardiology is the go-to podcast for interventional cardiologists, cardiac surgeons, and other healthcare professionals that manage cardiovascular conditions. Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty. ► https://www.backtable.com/app

Ep. 35 Interventional Cardiology Insights: A Journey with Innovations with Dr. Bill O’Neill

What do the very first TAVRs, rotational atherectomies, and angioplasty studies have in common? Dr. William O’Neill, an esteemed interventional cardiologist whose collaboration and innovation have shaped the field of interventional cardiology. In this episode of BackTable Cardiology, host Dr. Babar Basir welcomes his mentor Dr. William O’Neill. Together, they trace the evolution of interventional cardiology through personal stories, groundbreaking research, and the lasting impact of mentorship and teamwork on the specialty’s past, present, and future. --- Get the BackTable app https://www.backtable.com/app --- Timestamps 00:00 - Introduction 11:49 - Intracoronary Streptokinase Breakthrough 14:28 - Birth of Angioplasty: Initial Studies 23:20 - Primary PCI Proves Itself 28:29 - TAVR Breakthroughs 35:32 - Mentorship Lessons 40:17 - Future Cardiology Frontiers 46:22 - Presidential Heart History 53:51 - Conclusion --- More about this episode Dr. O’Neill details the evolution from bedrest-era MI care to intracoronary streptokinase and the advent of reperfusion, his early exposure to balloon angioplasty, and the pivotal studies that proved primary PCI’s superiority over thrombolytics amidst controversy. He explores how physician–engineer collaboration enabled innovations such as aortic valvuloplasty and early US TAVR, including the procedural challenges and regulatory hurdles faced. The episode also covers Dr. O’Neill’s mentorship philosophy, his optimism for the future of cardiology, including breakthroughs in cardiomyogenesis, xenotransplantation, and denervation therapies and his plan to remain up-to-date in the cardiology scene while beginning research on past presidents’ heart disease. --- Resources Dr. Babar Basir’s physician profile https://www.scai.org/mir-b-basir-do-fscai Dr. William O’Neill’s physician profile https://www.scai.org/william-w-oneill-md-mscai Thrombolysis and angioplasty in myocardial infarction (TAMI) trial https://www.jacc.org/doi/10.1016/S0735-1097%2887%2980430-8 Thrombolysis in Myocardial Infarction (TIMI) Study Group https://timi.org/about-timi/ Health-related quality of life one month after thrombolysis or primary PCI in patients with ST-elevation infarction. A DANAMI-2 sub-study. https://www.tandfonline.com/doi/10.1080/14017430510035989?url_ver=Z39.88-2003&rfr_id=ori:rid:crossref.org&rfr_dat=cr_pub%20%200pubmed Patient age and results of balloon aortic valvuloplasty: The mansfield scientific registry experience https://www.sciencedirect.com/science/article/pii/0735109791908738 Percutaneous Transcatheter Implantation of an Aortic Valve Prosthesis for Calcific Aortic Stenosis: First Human Case Description https://www.ahajournals.org/doi/10.1161/01.CIR.0000047200.36165.B8 Primary left ventricular unloading with delayed reperfusion in patients with anterior ST-elevation myocardial infarction: Rationale and design of the STEMI-DTU randomized pivotal trial https://pubmed.ncbi.nlm.nih.gov/36058253/ --- BackTable Cardiology is the go-to podcast for interventional cardiologists, cardiac surgeons, and other healthcare professionals that manage cardiovascular conditions. Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty. ► https://www.backtable.com/app

Ep. 34 Understanding Cardiac Mass Removal: Techniques Using Continuous Aspiration with Dr. Abdallah El Sabbagh

From clot to clear flow, minimally invasive aspiration devices are PAVE-ing the way for safer treatment of endocarditis and cardiac masses. In this BackTable Cardiology episode, host Dr. Hady Lichaa sits down with Dr. Abdallah El Sabbagh to discuss percutaneous continuous-flow aspiration for right- and select left-sided endocarditis and cardiac masses. --- Get the BackTable app https://www.backtable.com/app --- This podcast is supported by Angiodynamics https://9zfaiv.short.gy/cardiovascular-backtable --- Timestamps 00:00 - Introduction 03:43 - Lessons in Fibroelastoma 12:01 - Imaging Workup 14:24 - Transesophageal Echocardiography (TEE) vs Intracardiac Echocardiography (ICE) 17:52 - AngioVac System Components 20:33 - Access Strategy, Sheath Size and Flow Rates 23:41 - Adjunct Tools and Retrieval Options 31:35 - Using Continuous Aspiration 47:16 - Percutaneous AngioVac Vegetation Extraction (PAVE) Trial 53:17 - Future Devices Wishlist --- More about this episode Dr. El Sabbagh provides guidance on removing papillary fibroelastomas, emphasizing matching technique to mass characteristics and combining tools such as continuous aspiration with electrosurgical snaring to address adherent stalks. Their conversation covers patient selection for off-label endocarditis intervention, including intravenous drug use and Cardiac Implantable Electronic Device (CIED) lead infections, use of aspiration as definitive therapy, and imaging/workflow preferences. Dr. El Sabbagh details the AngioVac system, access strategies, adjunct devices, mitigating complications, and registry outcomes. He touches on the need for prospective studies, including the Percutaneous AngioVac Vegetation Extraction (PAVE) clinical trial. To finish the conversation, Drs. Lichaa and El Sabbagh look ahead to building future devices and provide advice on creating multidisciplinary programs as well as training pathways. --- Resources Dr. Hady Lichaa’s Provider Profile https://healthcare.ascension.org/find-care/provider/1336267533/hady-lichaa Dr. Abdallah El Sabbagh’s Provider Profile https://www.mayoclinic.org/biographies/el-sabbagh-abdallah-m-d/bio-20466764 Percutaneous AngioVac Vegetation Extraction (PAVE) to Remove Right Heart Vegetations in Patients With Infective Endocarditis - PAVE Clinical Trial https://clinicaltrials.gov/study/NCT07282002 --- BackTable Cardiology is the go-to podcast for interventional cardiologists, cardiac surgeons, and other healthcare professionals that manage cardiovascular conditions. Download the free BackTable app to get early access to new episodes, cases, and courses curated by physicians in your specialty. ► https://www.backtable.com/app