Safety and efficacy of percutaneous catheter-directed treatment for intermediate-high risk pulmonary embolism

Background Pulmonary embolism (PE) is globally the third most frequent acute cardiovascular syndrome, ranking high among the causes of cardiovascular mortality. Systemic thrombolytic therapy (STT) permits prompt reperfusion after pulmonary obstruction, nevertheless this treatment carries by itself an inherent risk of major bleeding events. Development of new therapies and interventions that allow us to achieve early lung reperfusion along with a reduced risk of bleeding are necessary. Purpose The aim of this study was to evaluate the safety and efficacy of percutaneous catheter-directed treatment (PCDT) on intermediate-high risk PE patients with high bleeding risk or contraindication for STT. Methods We consecutively included all patients with intermediate-high risk PE undergoing PCDT in two university hospitals. Clinical, echocardiographic and hemodynamic variables (pre and post PCDT) were collected, as well as major adverse cardiac and bleeding events during follow-up. Results Between February 2018 and January 2021, we included 30 consecutive patients admitted with intermediate-high risk PE who underwent PCDT. Median age was 60 years, interquartile range (IQR) 51–72, and 41% were women. 14 patients (46.6%) presented an absolute contraindication for STT, which was the main reason for performing PCDT. Catheter-directed local thrombolysis (CDLT) was performed in 27 (90%) patients and mechanical fragmentation-aspiration was performed in 12 (40%) of them. We observed a significant reduction in mean pulmonary artery pressure (mPAP, mmHg) after PCDT: 40±13 vs. 25±12, p<0.001; as well as in NT-proBNP concentrations (pg/ml) 48 hours post-PCDT: 4791±1077 vs. 2311±680, p=0.002, (Figure 1). Echocardiographic parameters of right ventricular (RV) dysfunction also experienced a significant improvement 72 hours post-PCDT: TAPSE (mm) 15±2 vs. 22±3, p=0.001, (Figure 2); basal RV diameter (mm) 51±4 vs. 41±2, p=0.001. During a median follow-up of 13 months, IQR (8–22), 1 patient died from non-cardiac cause and no patient presented a bleeding event. Conclusions PCDT for intermediate-high risk PE is safe and effective, producing an early reduction in mPAP, in prognostic biomarkers such as NT-proBNP, as well as an early improvement of classic echocardiographic parameters of RV dysfunction. FUNDunding Acknowledgement Type of funding sources: None. Figure 1 Figure 2

Triple guidance of choledochoscopy, ultrasonography, and computed tomography facilitates percutaneous catheter drainage of infected walled-off necrosis

Objectives Percutaneous catheter drainage (PCD) is usually performed to treat acute pancreatitis complicated by infected walled-off necrosis (WON). Insufficient drainage of infected WON may lead to a prolonged recovery process. Here, we introduce a modified PCD strategy that uses the triple guidance of choledochoscopy, ultrasonography, and computed tomography (CUC-PCD) to improve the therapeutic efficiency. Methods This study retrospectively analysed 73 patients with acute pancreatitis-related WON from January 2015 to January 2021. The first 38 patients were treated by ultrasonography/computed tomography-guided PCD (UC-PCD), and the next consecutive 35 patients by CUC-PCD. Perioperative data, procedural technical information, treatment outcomes, and follow-up data were collected. Results Demographic characteristics were statistically comparable between the two treatment groups (p > 0.05). After 48 h of PCD treatment, the CUC-PCD group achieved a significantly smaller size of the infected WON (p = 0.023), lower inflammatory response indexes (p = 0.020 for white blood cells, and p = 0.031 for C-reactive protein), and severity scores than the UC-PCD group (p < 0.05). Less catheter duration (p = 0.001), hospitalisation duration (p = 0.000), and global costs (p = 0.000) were observed in the CUC-PCD group compared to the UC-PCD group. There were no differences between the two groups regarding the rate of complications. Conclusions CUC-PCD is a safe and efficient approach with potential clinical applicability for treating infected WON owing to its feasibility in placing the drainage catheter at the optimal location in real time and performing primary necrosectomy without sinus tract formation and enlargement.

A Percutaneous Catheter Solution as a Spacer for Regurgitant Heart Valve Disease

Spacers, such as FORMA (Edwards Lifescience) or Mitraspacer, are used to treat mitral regurgitation or tricuspid regurgitations. However, they require external therapeutic liquid filler injection into the spacer device. This should be leak-tight over the time of implantation, which is a major limitation in device design. Here, we propose a self-expandable spacer with a nitinol inner mesh and expanded poly (tetrafluoroethylene) (ePTFE) coating that also functions as a spacer. We designed nitinol 3D mesh templates, coated with a commercially available low and high durometer ePTFE membrane. Finally, we implanted the spacer into a swine pulmonary artery and right atrium (superior vena cava) as an intervention technique. Twenty-four swine were used, except in two cases suspected of procedural infection. The results were analyzed in the remaining 22 cases and all devices were easily delivered and had good function in self-expansion and implantation. After eight weeks, all individuals were examined for gross and pathological analysis to determine the biological safety of the device. There was no evidence of damage or other abnormalities and increased postoperative endothelialization outside of ePTFE coatings. In conclusion, this study suggests using a self-expandable spacer to complement the medical limitations of the existing filling-type spacer devices.

Wireless endovascular nerve stimulation with a millimeter-sized magnetoelectric implant

Implanted bioelectronic devices have the potential to treat disorders that are resistant to traditional pharmacological therapies; however, reaching many therapeutic nerve targets requires invasive surgeries and implantation of centimeter-sized devices. Here we show that it is possible to stimulate peripheral nerves from within blood vessels using a millimeter-sized wireless implant. By directing the stimulating leads through the blood vessels we can target specific nerves that are difficult to reach with traditional surgeries. Furthermore, we demonstrate this endovascular nerve stimulation (EVNS) with a millimeter sized wireless stimulator that can be delivered minimally invasively through a percutaneous catheter which would significantly lower the barrier to entry for neuromodulatory treatment approaches because of the reduced risk. This miniaturization is achieved by using magnetoelectric materials to efficiently deliver data and power through tissue to a digitally-programmable 0.8 mm2 CMOS system-on-a-chip. As a proof-of-principle we show wireless stimulation of peripheral nerve targets both directly and from within the blood vessels in rodent and porcine models. The wireless EVNS concept described here provides a path toward minimally invasive bioelectronics where mm-sized implants combined with endovascular stimulation enable access to a number of nerve targets without open surgery or implantation of battery-powered pulse generators.

Characteristics Of Patients Of Descending Necrotizing Mediastinitis Thoracic, Cardiac And Vascular Surgery Subsection Thoracic In Dr. Mohammad Hoesin From 1 November 2019 To 30 November 2020

Background: Acute mediastinitis is an infection of the connective tissue of the interpleural mediastinal space. The infection may spread through the cervical spaces to the mediastinum, via negative intrathoracic pressure and gravity.1 Management of DNM with minimally invasive drainage, namely video-assisted thoracic surgical drainage (VATS),6 mediastinoscopy,7 and percutaneous catheter drainage,8,9 have been widely used. During early 1920s, data showed subsequent to broad-spectrum antibiotics, the mortality rate was about 40%.12 Furthermore, without prompt diagnosis and aggressive surgery, the mortality rate can reach up to 60%.13 Methods: This retrospective study has a descriptive research design. The number of samples is 19 subjects. Results: From January 1, 2019 to November 30, 2020 there were 19 DNM patients. In this study, most DNM patients were male, average age of 39 years, dental abscesses as the most common source of infection, neck exploration and sternotomy were the most common treatment option, most common outcome death, and the most common result of culture was Acinetobacter baumannii. Conclusion: Good non-operative and operative management can reduce mortality rate.