EKOS™ Jena Experience: Safety, Feasibility, and Midterm Outcomes of Percutaneous Ultrasound-Assisted Catheter-Directed Thrombolysis in Patients with Intermediate-High-Risk or High-Risk Pulmonary Embolism.

Background: Percutaneous catheter-based ultrasound-assisted thrombolysis (UACDT) is recommended for patients with intermediate-high-risk or high-risk pulmonary embolism (PE) in whom systemic thrombolysis has failed or is contraindicated. Aim: To evaluate the safety and efficiency of UACDT in patients with intermediate-high-risk or high-risk PE. Methods: Between October 2017 and January 2020, we performed UACDT using the EkoSonic™ Endovascular System (EKOS™) in 51 patients (21 males, age 63 ± 18 years) with a sPESI of 1.3 ± 0.7. The EKOS™-catheter was implanted within 24 h after admission. Over 15 hours, 11.5 mg of alteplase was administered per catheter. We evaluated right ventricular stress and cardiac biomarkers before and after UACDT. Results: 24 h post-UACDT, median RV/LV ratio decreased from 1.13 to 0.96 (p < 0.001) and the mean sPAP decreased from 47 ± 3 to 32 ± 2 mmHg + CVP (p < 0.0002). There were 6 major bleeding events resulting in transfusion. No stroke, myocardial infarction, right heart decompensation, or recurrent PE occurred. 31 patients (63%) were discharged without any signs of right ventricular stress. After at least 3 months, 73% of our patients did not show any signs of right ventricular dysfunction. The mean RV/LV ratio decreased to 0.75 ± 0.03 (p < 0.0001) in comparison with pre-UACDT, sPAP to 23 mmHg + CVP (p < 0.0001), and BNP to 40 pg/ml (p < 0.0001). Conclusions: The treatment with UACDT reduced right heart stress during the first 24 hours and midterm in patients with intermediate-high-risk or high-risk PE at an acceptable rate of severe complications.

Prognostication of neurologic outcome using gray-white-matter-ratio in comatose patients after cardiac arrest.

BACKGROUND: This study aimed to assess the prognostic value regarding neurologic outcome of CT neuroimaging based Gray-White-Matter-Ratio measurement in patients after resuscitation from cardiac arrest. METHODS: We retrospectively evaluated CT neuroimaging studies of 91 comatose patients resuscitated from cardiac arrest and 46 non-comatose controls. We tested the diagnostic performance of Gray-White-Matter-Ratio compared with established morphologic signs of hypoxic-ischaemic brain injury, e. g. loss of distinction between gray and white matter, and laboratory parameters, i. e. neuron-specific enolase, for the prediction of poor neurologic outcomes after resuscitated cardiac arrest. Primary endpoint was neurologic function assessed with cerebral performance category score 30 days after the index event. RESULTS: Gray-White-Matter-Ratio showed encouraging interobserver variability (ICC 0.670 [95% CI: 0.592-0.741] compared to assessment of established morphologic signs of hypoxic-ischaemic brain injury (Fleiss kappa 0.389 [95% CI: 0.320-0.457]) in CT neuroimaging studies. It correlated with cerebral performance category score with lower Gray-White-Matter-Ratios associated with unfavourable neurologic outcomes. A cut-off of 1.17 derived from the control population predicted unfavourable neurologic outcomes in adult survivors of cardiac arrest with 100% specificity, 50.3% sensitivity, 100% positive predictive value, and 39.3% negative predictive value. Gray-White-Matter-Ratio prognostic power depended on the time interval between circulatory arrest and CT imaging, with increasing sensitivity the later the image acquisition was executed. CONCLUSIONS: A reduced Gray-White-Matter-Ratio is a highly specific prognostic marker of poor neurologic outcomes early after resuscitation from cardiac arrest. Sensitivity seems to be dependent on the time interval between circulatory arrest and image acquisition, with limited value within the first 12 h.

Renal denervation with cryoenergy as second-line option is effective in the treatment of resistant hypertension in non-responders to radiofrequency ablation.

AIMS: Renal denervation (RDN) with radiofrequency (RF) is being used to treat resistant hypertension (rHTN). As 15-30% of treated patients are non-responders to RDN, we investigated whether RDN with cryoenergy can serve as a second-line option. METHODS AND RESULTS: Ten non-responder patients (mean age 55 years, six male) with rHTN were treated with cryoenergy for RDN. In order to qualify as non-responders, patients had to show systolic 24 hr ambulatory BP (ABP) ≥150 mmHg (median ABP 183/102 mmHg, median office- based BP [OBP] 191/108 mmHg) despite treatment with ≥4 different antihypertensive drugs (mean 6), and further not show a reduction of systolic ABP ≥10 mmHg at ≥3 months after RDN with RF. The three/six/12-month follow-up (FU) comprised clinical and biochemical evaluation, OBP and ABP measurement. Additionally, at six months, duplex sonography was performed. Cryoablation with a 7 Fr cryoablation catheter (Freezor® Xtra; Medtronic, Minneapolis, MN, USA) was performed in all patients without complications (four applications in both renal arteries, every four minutes, temperature -75°C). At three, six, and 12 months we found a reduction in systolic OBP of -41/-47/-61 mmHg (n=10/7/6; p=0.044 for all), diastolic OBP of -18/-14/-34 mmHg, systolic ABP of -38/-35/-52 mmHg (n=9/7/6, p=0.014 for all), and diastolic ABP of -20/-13/-18 mmHg (p=0.043 for all), respectively. During FU, no complications occurred and the renal function remained unchanged. CONCLUSIONS: The significant reduction in systolic OBP and ABP observed qualifies RDN with cryoenergy as an effective second-line therapeutic option in non- responders to RDN with RF.