Dennis Rossi, MD, was in a bit of a quandary during his March 2014 Florida vacation. Never sick a day in his life and 72 at the time, the interventional radiologist from Nassau County developed excruciating pain. He tried to tough it out in his hotel room but ended up in a Miami hospital Emergency Department, where a computed tomography (CT) scan revealed a large kidney stone.
Florida doctors inserted a stent into the kidney that Dr. Rossi would need to have removed back home in New York. With removal of the stent, the stone would drop out. It seemed like a simple enough plan.
After recovering in the Florida hospital for two days, Dr. Rossi boarded a plane to return home. The flight was delayed, and the plane sat on the tarmac for hours. Cramped next to the window and not wanting to disturb the elderly couple seated next to him, he stayed put for the duration. By the time the flight landed in New York, he felt awful and extremely weak.
“I went straight to bed when I got home. When I woke up the next morning, I fainted,” Dr. Rossi said. He visited his urologist, who felt these symptoms were unrelated to the kidney stone. Together, they suspected a silent heart attack or pulmonary embolism. The urologist called an ambulance to take Dr. Rossi to North Shore University Hospital (NSUH).
Another Trip to the Emergency Department
While in the NSUH Emergency Department, Dr. Rossi was diagnosed with blood clots in his lungs, a condition called pulmonary embolism that almost always results from clots in the veins of the legs that dislodge and travel to the lungs. Once lodged in the lungs, the blockage puts strain on the heart and prevents oxygenated blood from flowing back to the heart.
Dr. Rossi saw the CT scans of his lungs taken at NSUH. “I said, ‘Holy cow, those are mine?’ I had clots that were the size of golf balls.”
The clots formed due to lying immobile in the Miami hospital for two days, then sitting cramped on the plane. Dr. Rossi was admitted to NSUH, and for the next several hours his condition worsened. Mitchell Weinberg, MD, director of peripheral vascular intervention at NSUH and Lenox Hill Hospital in Manhattan, sprang into action.
“When I first saw Dennis, he had a submassive pulmonary embolism, where enough blood is getting through the lungs to maintain sufficient blood pressure, but the heart is under strain trying to pump and can become damaged,” said Dr. Weinberg.
With an elevated heart rate and a low oxygen saturation, Dr. Rossi needed treatment soon. “My oxygen saturation was down to 74 percent. To give you an idea of how bad that is, 70 percent is dead!” said Dr. Rossi.
Weighing the Options
Dr. Weinberg consulted with a team of specialists about treatment options, including intravenous infusion of clot-busting drugs. This less invasive option carries an undesirable five percent risk of fatal bleeding in the brain and 10 percent risk of bleeding in other organs.
Dr. Weinberg proposed a more aggressive procedure: inserting a special type of catheter into a vein in the groin and navigating it up through the heart and into the lungs. This particular catheter contains miniature holes that allow delivery of extremely small doses of clot-busting drugs directly to the clots. The doses are so low that the risk for bleeding in the brain drops to between 0 and 0.5 percent. The catheter also contains a smaller tube with tiny ultrasound probes attached; when activated, the probes vibrate to help disburse the drug within the clots.
“Dennis was very sick with a substantial pulmonary embolism, and he needed a more aggressive approach,” said Dr. Weinberg. Dr. Rossi felt comfortable with this decision.
Dr. Weinberg performed the procedure and placed two catheters — one into the right pulmonary artery and another into the left — to deliver the low-dose, clot-busting drug and ultrasound probes. By the next morning, Dr. Rossi’s oxygen saturation was up to about 95 percent, near normal.
“I have nothing but accolades for Dr. Weinberg. He was knowledgeable and efficient, had confidence in his skills and was 100 percent attentive to me,” said Dr. Rossi. “I retired after that event last year, but now that I’m recovered, I feel 35!”
Evolution of Care
The Pulmonary Embolism Response Team, or PERT, is a recent advancement in pulmonary embolism patient care at NSUH. Emergency Department staff activates a team of specialists from emergency medicine, interventional cardiology, pulmonology, hematology and cardiothoracic surgery who collaborate on patient evaluation and treatment. LIJ Medical Center and Lenox Hill Hospital are also rolling out a PERT.
Read the next article, A Next-Gen Approach to Open-Heart Surgery