Dr. Tod Engelhardt is a cardiovascular and thoracic surgeon who is revolutionizing the treatment of blood clots. His use of ultrasound technology, combined with a catheter to deliver clot dissolving drugs, is saving the lives of patients suffering from major pulmonary embolisms.
Tell me a little bit about yourself.
My name is Tod Engelhardt. I’m a cardiovascular and thoracic surgeon from New Orleans, Louisiana. I practice at East Jefferson General Hospital, which is in the suburbs of New Orleans, and I have a special interest, not only in cardiac and vascular surgery as well as thoracic, but also specifically in endovascular treatment of venous thrombosis, namely DBT and pulmonary embolism.
How did you get into practicing medicine?
Well, you know I’ve always, since high school days, wanted to be a physician. I’m the first in my family, so I can’t blame it on anyone else. It’s just something that I tended to be attracted towards. Science has always fascinated me and the human body fascinated me so it was natural that I do something in the field of medicine.
What are you presenting on this weekend?
I’m talking about a new, novel treatment for major pulmonary embolism. It uses new ultrasound technology combined with a catheter that delivers a clot dissolving drug directly into the pulmonary arteries.
How does this differ from previous technology?
Well, the treatment for a blood clot to the lung typically, and it is presently still the standard of care, is to thin blood, to give what’s called Heparin and then Coumadin, which are two drugs that prevent blood from clotting. Those drugs don’t actively dissolve clots; they just prevent more clot from forming. We have found that if you rapidly dissolve the blood clot where it doesn’t belong, then patients tend to do better. So we have a drug that actively dissolves clot, but the downside is that if you give a normal dose intravenously, it’s dangerous. People can bleed and can have catastrophic bleeding. So, the dilemma is we’d like to give the clot dissolving drug, but we don’t want the patient to bleed to death or have an intracranial hemorrhage. So, we have now a device that uses ultrasound technology, and, because of the ultrasound technology, allows us to deliver one-fifth of the normal dose of this drug that can be so dangerous. So, if we give one fifth of the dose of the drug, we have eliminated the bleeding tendency, plus we have found that combined with the ultrasound technology, that we get the same result. So we have the benefit of using the clot dissolving drug and we’re using much less of it. And the only reason we can say that is because we’re delivering the drug directly into the clot, directly into the pulmonary artery, and it’s worked very well.
How do you think this will continue to improve in the next five to ten years?
I think that it’s going to continue to work very well, but that I think we need to educate, not only the public, but physicians as well to use this technology. I think that if we look at categories of severity of blood clots in the lung, they’re all different and certain major blood clots have much higher mortality rates. You can die much more easily with a major clot, whereas minor, small clots, people do quite well. The natural tendency of the body is to dissolve the clot. But, as of right now, we’re using the same treatment for all three classes—major and minor, and in major we break down into submassive and massive. All that means is that when you get so much blood clot blocking the flow of blood into the lungs, then you go into right heart failure. Patients, when they die of pulmonary embolism, die of right heart failure. So, I think it’s prudent that we dissolve that clot as quickly as possible, and by doing so, I think patients’ lives will be saved and down the road they’ll be spared the long–term complication of pulmonary hypertension, which can be debilitating and conventionally kill the patent ten years later.
What do you think patients most need to know about this?
I think they need to know that, number one, pulmonary embolism is a very serious, life threatening disease, and it’s not a disease of the elderly patient, of the sick patient. Pulmonary embolism has claimed the lives of young people—very healthy, athletic people. It’s claimed the lives of middle-aged businessmen. And it’s not just a disease of the elderly. It’s certainly more prominent and more often seen in patients with cancer, and patients who have just had big surgeries and are bedridden for awhile. But I think that the public needs to know that in all cases, that just thinning the blood with Heparin and Coumadin is not adequate and there’s something more that needs to be done. And it depends on how the heart is tolerating the blood clot. If the heart’s having a hard time and looks like it’s straining to pump blood past the obstruction, something needs to be done right away. That should be treated as an emergency, and right now it’s not being treated that way. They’re just being placed on the blood thinner, and they either survive or they don’t.
Do you have any specific patient success stories that you’d like to share?
We’ve done now fifty-five patients at my institution. They’ve all done quite well. It all started with the very first patient that I used the device. I had used it in the leg prior to this first case in the pulmonary artery. It was an 84-year-old gentleman who had had pulmonary bypass surgery two weeks prior to coming into the emergency room that morning. I got called to see the patient who now was in shock. I had very low blood pressure, and he was not responding to the normal medications that you would give to raise the blood pressure. He had a huge blood clot in his lungs. It was in his right side of his heart, and he wasn’t doing well. The possibility of taking him up to the operating room to open his chest again and doing a procedure that carries a high risk, I think would have been foolhardy. I don’t think he would have survived that. And we would have liked to have given him the clot resolving drug immediately, in the emergency room, but we felt like his risk of bleeding was exceedingly high and that he probably wouldn’t do well with that therapy. So I convinced the cardiologist to let me try placement of this catheter very quickly into the pulmonary artery and to use this therapy that we’re using now, and it worked very well. Just before we were going to do CPR on the patient because he deteriorated quite rapidly, we were able to get the catheter in place, give him a little of the drug, activate the ultrasound, and, not going into all the details, he left the hospital four days later and continues to do well until this day. So, that sold me on the therapy. Here I had the sickest of the sick patients who responded very rapidly and did very well. Now I treat all of my patients that have major pulmonary emboli the same way. I use this therapy. Fifty-five patients later, they’ve all done quite well. I’ve achieved the desired result with minimal episodes of bleeding, so that’s the way I treat it, and that’s the way I’m going to continue treating my patients.
What advice do you have for patients?
I’m going to say, to be educated. To try to prevent pulmonary embolism in the first place. Pulmonary embolism is the most preventable cause of in-hospital deaths, and continues to be so. There are 600,000 cases per year. Patients need to know that when they have any type of chest discomfort or shortness of breath or dizziness, that this can be a pulmonary embolism and they need to get to the hospital right away. A CAT scan of the chest needs to be performed, some blood work needs to be performed, and if it’s a major clot, patients should inquire about the best therapy that we have for that particular problem. Too often I will get called to treat a patient with a major blood clot in the lungs 24 to 40 hours after they’ve been admitted to the hospital , and by the time I’m asked to see them, they have already required CPR a couple times. They are very, very sick. They’re much sicker than when they came in the hospital. And it just makes no sense. If I had seen these particular patients as soon as they came in the hospital, the treatment would have been performed and they would have been just fine. So I think the take-home message to the public is you need to treat this like a bad heart attack. Some patients, you need to go to intervention right away.
Is there anything else that you’d like to share?
Well, I just think that we could possibly be changing the standard of care with this new therapy. I think we have a huge unmet need in a certain population of pulmonary embolism patients. I don’t think we’re treating these patients adequately. I think we have something better to offer. And I think we’re now, finally demonstrating where this is the case and we need to do something better than we’re doing now.