{"status":"ok","message-type":"work","message-version":"1.0.0","message":{"indexed":{"date-parts":[[2026,9,2]],"date-time":"2026-09-02T12:21:05Z","timestamp":1788351665289,"version":"build-2803163510"},"reference-count":17,"publisher":"BMJ","issue":"1","license":[{"start":{"date-parts":[[2026,6,22]],"date-time":"2026-06-22T00:00:00Z","timestamp":1782086400000},"content-version":"unspecified","delay-in-days":172,"URL":"https:\/\/creativecommons.org\/licenses\/by-nc\/4.0\/"}],"content-domain":{"domain":["bmj.com"],"crossmark-restriction":true},"short-container-title":["Open Heart"],"accepted":{"date-parts":[[2026,6,7]]},"published-print":{"date-parts":[[2026,1]]},"abstract":"<jats:sec>\n                    <jats:title>Background<\/jats:title>\n                    <jats:p>Ultrasound-assisted catheter-directed thrombolysis using the EkoSonic Endovascular System (EKOS) is an established treatment for intermediate high-risk pulmonary embolism (IHR-PE). However, the optimal timing of treatment initiation remains uncertain. Early right ventricular (RV) unloading may improve outcomes by reducing RV pressure overload and preventing haemodynamic deterioration.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Methods<\/jats:title>\n                    <jats:p>We conducted a retrospective multicentre analysis of patients with IHR-PE treated with EKOS at three tertiary centres. Patients were stratified by time from CT-confirmed diagnosis to EKOS initiation: early (&lt;12\u2009hours) versus delayed (&gt;12\u2009hours). Echocardiographic parameters included RV\/left ventricular (LV) ratio, tricuspid annular plane systolic excursion (TAPSE), LV ejection fraction (LVEF) and systolic pulmonary artery pressure (sPAP). Secondary outcomes were intensive care unit (ICU) length of stay, complications, bleeding events and in-hospital mortality. 3-month follow-up was available in two centres.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Results<\/jats:title>\n                    <jats:p>Overall, 152\u2009patients were included (early n=106; delayed n=46) in the study. Baseline characteristics were largely comparable, although dyspnoea New York Heart Association (NYHA) class II\u2013III was more frequent in the early group (NYHA III: 73% vs 46%, p=0.001). Both groups showed significant improvements in RV\/LV ratio, TAPSE, sPAP and LVEF (all p&lt;0.001). Early treatment resulted in numerically greater RV functional improvement (Early \u0394 Discharge (D)-Admission (A) TAPSE early 4.86\u00b15.14\u2009mm vs delayed \u0394 D-A 3.5\u00b15\u2009mm), without statistically significant differences between groups. At 3-month follow-up, RV recovery measured by TAPSE was comparable. Early EKOS therapy was associated with a significantly shorter ICU stay (median 24\u2009hours vs 45.5\u2009hours, p=0.033), fewer PE-related complications (p=0.03), while procedure-related complications and in-hospital mortality did not differ.<\/jats:p>\n                  <\/jats:sec>\n                  <jats:sec>\n                    <jats:title>Conclusions<\/jats:title>\n                    <jats:p>In IHR-PE, EKOS initiation within 12 hours is associated with a significantly shorter ICU stay and significantly less PE-related complications. These findings support early EKOS treatment strategies and warrant confirmation in prospective studies.<\/jats:p>\n                  <\/jats:sec>","DOI":"10.1136\/openhrt-2026-004271","type":"journal-article","created":{"date-parts":[[2026,6,22]],"date-time":"2026-06-22T14:55:42Z","timestamp":1782140142000},"page":"e004271","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":0,"title":["Early versus delayed EKOS thrombolysis in intermediate-high risk pulmonary embolism: a retrospective multicentre analysis"],"prefix":"10.1136","volume":"13","author":[{"ORCID":"https:\/\/orcid.org\/0009-0002-1035-0285","authenticated-orcid":false,"given":"Julia","family":"Schulten-Baumer","sequence":"first","affiliation":[{"name":"University Heart Center - Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein (UKSH), Campus L\u00fcbeck, University of L\u00fcbeck, L\u00fcbeck, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Abdelrahman","family":"Elhakim","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine and Cardiology, Sch\u00f6n Klinik Neustadt, Neustadt in Holstein, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Peter","family":"Radke","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine and Cardiology, Sch\u00f6n Klinik Neustadt, Neustadt in Holstein, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Andreas","family":"Schuchert","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine and Cardiology, Friedrich-Ebert-Hospital Neum\u00fcnster, Neum\u00fcnster, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Bj\u00f6rn","family":"St\u00f6cker","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine and Cardiology, Friedrich-Ebert-Hospital Neum\u00fcnster, Neum\u00fcnster, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Niklas","family":"Schofer","sequence":"additional","affiliation":[{"name":"Department of Internal Medicine and Cardiology, Friedrich-Ebert-Hospital Neum\u00fcnster, Neum\u00fcnster, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Matthias","family":"Mezger","sequence":"additional","affiliation":[{"name":"University Heart Center - Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein (UKSH), Campus L\u00fcbeck, University of L\u00fcbeck, L\u00fcbeck, Germany"},{"name":"Partner Site North, German Center for Cardiovascular Disease, L\u00fcbeck, BE, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-7919-4113","authenticated-orcid":false,"given":"Elias","family":"Rawish","sequence":"additional","affiliation":[{"name":"University Heart Center - Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein (UKSH), Campus L\u00fcbeck, University of L\u00fcbeck, L\u00fcbeck, Germany"},{"name":"Partner Site North, German Center for Cardiovascular Disease, L\u00fcbeck, BE, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0003-1957-3741","authenticated-orcid":false,"given":"Thomas","family":"Stiermaier","sequence":"additional","affiliation":[{"name":"University Heart Center - Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein (UKSH), Campus L\u00fcbeck, University of L\u00fcbeck, L\u00fcbeck, Germany"},{"name":"Partner Site North, German Center for Cardiovascular Disease, L\u00fcbeck, BE, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Ingo","family":"Eitel","sequence":"additional","affiliation":[{"name":"University Heart Center - Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein (UKSH), Campus L\u00fcbeck, University of L\u00fcbeck, L\u00fcbeck, Germany"},{"name":"Partner Site North, German Center for Cardiovascular Disease, L\u00fcbeck, BE, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Tobias","family":"Schmidt","sequence":"additional","affiliation":[{"name":"Department of Cardiology and Internal medicine, Asklepios Westklinikum Hamburg, Hamburg, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"given":"Christian","family":"Frerker","sequence":"additional","affiliation":[{"name":"University Heart Center - Department of Cardiology, Angiology and Intensive Care Medicine, University Hospital Schleswig-Holstein (UKSH), Campus L\u00fcbeck, University of L\u00fcbeck, L\u00fcbeck, Germany"},{"name":"Partner Site North, German Center for Cardiovascular Disease, L\u00fcbeck, BE, Germany"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2026,6,22]]},"reference":[{"key":"2026090204551433000_13.1.e004271.1","doi-asserted-by":"crossref","first-page":"1580","DOI":"10.1111\/jth.12698","article-title":"Thrombosis: a major contributor to the global disease burden","volume":"12","author":"Raskob","year":"2014","journal-title":"Journal of Thrombosis and Haemostasis"},{"key":"2026090204551433000_13.1.e004271.2","doi-asserted-by":"crossref","first-page":"037","DOI":"10.1055\/s-2008-1052304","article-title":"Ultrasound-Enhanced Thrombolysis: EKOS EndoWave Infusion Catheter System","volume":"25","author":"Owens","year":"2008","journal-title":"Semin intervent Radiol"},{"key":"2026090204551433000_13.1.e004271.3","doi-asserted-by":"publisher","DOI":"10.1016\/j.jcin.2015.04.020"},{"key":"2026090204551433000_13.1.e004271.4","first-page":"1401","article-title":"A Randomized Trial of the Optimum Duration of Acoustic Pulse Thrombolysis Procedure in Acute Intermediate-Risk Pulmonary Embolism","volume":"11","author":"Tapson","year":"2018","journal-title":"JACC: Cardiovascular Interventions"},{"key":"2026090204551433000_13.1.e004271.5","doi-asserted-by":"publisher","DOI":"10.1161\/CIRCULATIONAHA.113.005544"},{"key":"2026090204551433000_13.1.e004271.6","doi-asserted-by":"crossref","first-page":"543","DOI":"10.1093\/eurheartj\/ehz405","article-title":"ESC Guidelines for the diagnosis and management of acute pulmonary embolism developed in collaboration with the European Respiratory Society (ERS)","volume":"41","author":"Konstantinides","year":"2019","journal-title":"Eur Heart J"},{"key":"2026090204551433000_13.1.e004271.7","doi-asserted-by":"crossref","first-page":"1979","DOI":"10.1056\/NEJMoa2516567","article-title":"Ultrasound-Facilitated, Catheter-Directed Fibrinolysis for Acute Pulmonary Embolism","volume":"394","author":"Rosenfield","year":"2026","journal-title":"N Engl J Med"},{"key":"2026090204551433000_13.1.e004271.8","doi-asserted-by":"crossref","unstructured":"Zhang RS , Yuriditsky E , Zhang P , et al . Impact of Time to Catheter-Based Therapy on Outcomes in Acute Pulmonary Embolism. Circ: Cardiovascular Interventions 2025;18. doi:10.1161\/CIRCINTERVENTIONS.124.014499","DOI":"10.1161\/CIRCINTERVENTIONS.124.014499"},{"key":"2026090204551433000_13.1.e004271.9","doi-asserted-by":"publisher","DOI":"10.1001\/jama.2009.1754"},{"key":"2026090204551433000_13.1.e004271.10","doi-asserted-by":"crossref","first-page":"328","DOI":"10.1016\/j.amjms.2025.06.011","article-title":"Cost analysis of mechanical thrombectomy vs catheter-directed thrombolysis vs anticoagulation alone for pulmonary embolism","volume":"370","author":"Kattih","year":"2025","journal-title":"Am J Med Sci"},{"key":"2026090204551433000_13.1.e004271.11","first-page":"157","article-title":"Early Versus Delayed Use of Ultrasound-Assisted Catheter-Directed Thrombolysis in Patients With Acute Submassive Pulmonary Embolism","volume":"30","author":"Edla","year":"2018","journal-title":"J Invasive Cardiol"},{"key":"2026090204551433000_13.1.e004271.12","doi-asserted-by":"crossref","first-page":"419","DOI":"10.21037\/atm.2019.07.89","article-title":"Is there an optimal \u201cdoor to cath time\u201d in the treatment of acute pulmonary embolism with catheter-directed thrombolysis?","volume":"7","author":"Rawal","year":"2019","journal-title":"Ann Transl Med"},{"key":"2026090204551433000_13.1.e004271.13","doi-asserted-by":"crossref","first-page":"285","DOI":"10.1093\/ehjci\/jeaa243","article-title":"The echocardiographic ratio tricuspid annular plane systolic excursion\/pulmonary arterial systolic pressure predicts short-term adverse outcomes in acute pulmonary embolism","volume":"22","author":"Lyhne","year":"2021","journal-title":"Eur Heart J - Cardiovasc Imaging"},{"key":"2026090204551433000_13.1.e004271.14","first-page":"817","article-title":"Right ventricular-pulmonary artery coupling for prognostication in acute pulmonary embolism","volume":"13","author":"Lyhne","year":"2024","journal-title":"Eur Heart J Acute Cardiovasc Care"},{"key":"2026090204551433000_13.1.e004271.15","doi-asserted-by":"crossref","first-page":"507","DOI":"10.1007\/s00392-025-02817-y","article-title":"Safety and efficacy of thrombolysis with the EkoSonic Endovascular System for intermediate-high risk pulmonary embolism during on- and off-hours: a multicenter study","volume":"115","author":"Schulten-Baumer","year":"2026","journal-title":"Clin Res Cardiol"},{"key":"2026090204551433000_13.1.e004271.16","doi-asserted-by":"publisher","DOI":"10.1007\/s11239-006-5572-y"},{"key":"2026090204551433000_13.1.e004271.17","doi-asserted-by":"publisher","DOI":"10.1016\/j.ahj.2022.05.011"}],"updated-by":[{"DOI":"10.1136\/openhrt-2026-004271corr1","type":"correction","label":"Correction","source":"publisher","updated":{"date-parts":[[2026,7,14]],"date-time":"2026-07-14T00:00:00Z","timestamp":1783987200000}}],"container-title":["Open Heart"],"original-title":[],"language":"en","link":[{"URL":"https:\/\/syndication.highwire.org\/content\/doi\/10.1136\/openhrt-2026-004271","content-type":"unspecified","content-version":"vor","intended-application":"similarity-checking"}],"deposited":{"date-parts":[[2026,9,2]],"date-time":"2026-09-02T11:55:29Z","timestamp":1788350129000},"score":1,"resource":{"primary":{"URL":"https:\/\/openheart.bmj.com\/lookup\/doi\/10.1136\/openhrt-2026-004271"}},"subtitle":[],"short-title":[],"issued":{"date-parts":[[2026,1]]},"references-count":17,"journal-issue":{"issue":"1","published-online":{"date-parts":[[2026,6,22]]},"published-print":{"date-parts":[[2026,1]]}},"alternative-id":["10.1136\/openhrt-2026-004271"],"URL":"https:\/\/doi.org\/10.1136\/openhrt-2026-004271","relation":{},"ISSN":["2053-3624"],"issn-type":[{"value":"2053-3624","type":"electronic"}],"subject":[],"published":{"date-parts":[[2026,1]]}}}