Background: Ultrasound-facilitated and catheter-directed low-dose fibrinolysis (EKOS) has shown favorable hemodynamic and safety outcomes in intermediate- to high-risk pulmonary embolism (PE) cases. Objectives: This prospective single-arm monocentric study assessed the effects of using a delivery catheter for fibrinolysis as a novel approach for acute intermediate- to high-risk patients on pulmonary artery hemodynamics PE. Methods: Forty-five patients (41 intermediate–high and 4 high risk) with computer tomography (CT)-confirmed PE underwent EKOS therapy. By protocol, a total of 6 mg of tissue-plasminogen activator (t-PA) was administered over 6 h in the pulmonary artery (unilateral 6 mg or bilateral 12 mg). Unfractionated heparin was provided periprocedurally. The primary safety outcome was death, as well as major and minor bleeding within 48 of procedure initiation and at 90 days. The primary effectiveness outcomes were: 1. to assess the difference in pulmonary artery pressure from baseline to 6 h post-treatment as a primary precise surrogate marker, and 2. to determine the echocardiographic RV/LV ratio from baseline to 48 h and at 90 days post-delivery. Results: Pulmonary artery pressure decreased by 15/6/10 mmHg (p < 0.001). The mean RV/LV ratio decreased from 1.2 ± 0.85 at baseline to 0.85 ± 0.12 at 48 and to 0.76 ± 0.13 at 90 days (p < 0.001). Five patients (11%) died within 90 days of therapy. Conclusions and Highlights: Pulmonary artery hemodynamics were assessed using a delivery catheter for fibrinolysis, which is reproducible for identifying PE at risk of adverse outcomes. The results matched the right heart catheter results in EKOS and Heparin arm of Ultima trial, thereby confirming the validity of this potential diagnostic tool to assess therapy effectiveness and thereby reduce additional procedure-related complications, hospital residency, and economics. These results stress the importance of having an interdisciplinary team involved in the management of PE to evaluate the quality of life of these patients and this protocol shortens ICU admission to 6 h.

Ultrasound-accelerated thrombolysis (USAT) is an advanced interventional therapy for patients with intermediate–high-risk pulmonary embolism (PE) who deteriorated on anticoagulation or for high-risk patients for whom systemic thrombolysis is contraindicated. The aim of this study is to investigate the safety and efficacy of this therapy with a focus on the improvement of vital signs and laboratory parameters. Seventy-nine patients with intermediate–high-risk PE were treated with USAT from August 2020 to November 2022. The therapy significantly decreased the mean RV/LV ratio from 1.2 ± 0.22 to 0.9 ± 0.2 (p < 0.001) as well as the mean PAPs from 48.6 ± 11 to 30.1 ± 9.0 mmHg (p < 0.001). The respiratory and heart rate decreased significantly (p < 0.001). Serum creatinine decreased significantly from 1.0 ± 0.35 to 0.9 ± 0.3 (p < 0.001). There were 12 access-associated complications, which could be treated conservatively. One patient had haemothorax after the therapy and had to be operated on. USAT is an effective therapy for patients with intermediate–high-risk PE, with favourable hemodynamic, clinical, and laboratory outcomes.

Background: Pulmonary embolism (PE) is a common cardiovascular disease. Elderly patients with acute PE have very high mortality rates. Data concerning the safety and effectiveness of ultrasound-accelerated thrombolysis (USAT) in this age group are lacking. Methods: Nineteen octogenarians with acute pulmonary embolism underwent USAT between August 2020 and February 2023 at two centres in Germany and were retrospectively analysed. The main efficacy measures were the right ventricle to left ventricle diameter (RV/LV) ratio, systolic right ventricle function, and invasive and echocardiographic measured systolic pulmonary artery pressure (sPAP). The main safety measures were in-hospital death and the bleeding rate according to the GUSTO bleeding score. Results: USAT was associated with an improved RV/LV ratio (0.36 ± 0.29, p < 0.001), systolic right ventricle function (5.0 ± 3.8, p < 0.001), and systolic pulmonary artery pressure (sPAP) at 24 h after therapy (24.2 ± 11.2 mmHg and 19 ± 13.4 mmHg, p < 0.001). No in-hospital deaths or bleeding complications occurred. Conclusions: USAT with EKOSTM may be a safe and effective therapeutic option for octogenarians with acute pulmonary embolism.

Background Injury of the great cardiac vein during circumflex coronary artery intervention is not discussed enough in the literature. In addition, relationship between the great cardiac vein and circumflex artery is highly variable and practically unpredictable in 30% of cases. This report describes a rare case of great cardiac vein injury during circumflex artery intervention. Case Presentation An 80-year-old man with known ischemic heart disease was admitted with instable anginal pain for urgent coronary angiography. Cx-PCI of proximal-to-medial high-grade calcified stenosis was performed. Two hours later, the patient developed pericardial tamponade. Pericardiocentesis revealed a venous bloody effusion. Due to continuous bleeding, an urgent exploratory thoracotomy was performed. Intraoperatively, a large pericardial hematoma in the Cx region was evacuated. The perforation site was sought and identified as a tear at the great cardiac vein. Further hospitalization was uneventful, and the patient was discharged after one week. Clinical and echocardiographic outcomes were favorable at the 3-month follow-up. Conclusion A great cardiac vein injury during percutaneous coronary intervention is a diagnosis of exclusion if there is a venous pericardial effusion directly after PCI and no injury of the right ventricle or surrounding structures and thoracic CT demonstrates a pericardial hematoma in the PCI region, especially the Cx region. A hematoma can deteriorate the hemodynamic status without effusion “dry tamponade”. Treatment should be addressed according to hemodynamics. A conservative therapy, pericardiocentesis, catheter-based bailout intervention or even an explorative pericardiotomy could be imperative to evacuate the hematoma and seal the injured vein.