Background and Objective: Catheter-directed interventions (CDI) for pulmonary embolism (PE) have emerged as alternatives to systemic thrombolysis for patients requiring reperfusion, enabling thrombus burden reduction through low-dose local thrombolysis or mechanical thrombectomy. Despite encouraging hemodynamic and clinical outcomes, procedure-specific complications are poorly characterized in the literature. This narrative review aims to synthesize the reported complications of CDI in acute PE and provide practical management strategies. Methods: A PubMed search covering 2014–2025, limited to articles published in English or Spanish, complemented by reference screening, identified randomized clinical trials and prospective or retrospective registries of CDI in acute PE reporting safety outcomes. These studies were used to construct a comprehensive overview of CDI-related complications, while additional registries, case reports, and case series were examined to describe rare events not captured by primary studies, as well as expert insights when evidence was insufficient or unavailable. Key Content and Findings: Complications of CDI in acute PE encompass a broad and heterogeneous spectrum including access-site complications, right-heart injury, pulmonary arterial lesions, catheter malfunction and mechanical complications, and hemodynamic deterioration. Their incidence varies considerably across studies, and the absence of standardized definitions or classifications limits accurate assessment of the true frequency and clinical impact of those adverse events. Conclusions: Based on the available evidence, this narrative expert review examines the spectrum of CDI-related complications in acute PE. It seeks to bridge the gap between innovation and safety by equipping clinicians and interventionalists with practical guidance for the recognition, prevention, and management of these adverse events.

Tricuspid transcatheter edge-to-edge repair (T-TEER) is an emerging treatment option in symptomatic patients with severe tricuspid regurgitation (TR) and high surgical risk. TEER devices can become infected. An 87-year-old female with previous admissions for heart failure was diagnosed with massive atrial-secondary TR. The case was discussed in the Heart-Team meeting. Based on her surgical risk (Society of Thoracic Surgeons score: 15.3%), it was decided to perform tricuspid transcatheter edge-to-edge repair (T-TEER). Six months later, the patient was readmitted for fever, chills, tachycardia, hypotension, and peripheral hypoperfusion with skin lividity. Blood cultures were positive for methicillin-resistant Staphylococcus epidermidis. Transesophageal echocardiography revealed torrential TR and a large 27- × 23-mm hypoechoic mass attached to a Pascal device. Surgical risk was prohibitive. We opted for medical treatment (daptomycin 12 mg/kg/d and rifampicin 1200 mg daily). The patient developed progressive signs of uncontrolled sepsis and ultimately died. Infectious endocarditis after TEER is rare, but it has a high mortality rate. There are no reports on how to approach T-TEER-related infective endocarditis.

Background: There is evidence that pacemaker implantation can trigger Takotsubo syndrome (TTS). However, limited information is available on the prognosis of TTS caused by this trigger, so our study aims to elucidate the clinical features, presentation, and prognostic factors associated with this syndrome in this specific situation. Methods: We analyzed a group of patients with TTS triggered by pacemaker implantation (n = 41), including consecutive cases from the multicenter registry on takotsubo syndrome (RETAKO) and patients identified through a systematic literature search, and compared them to the general RETAKO cohort (n = 1559). We performed a 1:3 propensity score matching (PSM) based on dyslipidemia, diabetes mellitus, smoker/ex-smoker status, syncope, angina, vagal symptoms, and physical/mixed trigger, generating two balanced groups. Results: Compared to other triggers, TTS associated with pacemaker implantation was linked to a longer corrected QT interval (551.2 ms vs. 502.5 ms, p = 0.005), lower left ventricular ejection fraction (34.8% vs. 47.3%, p < 0.001), a higher proportion of acute kidney injury (29.3% vs. 11.0%, p = 0.001), and an increased rate of cardiogenic shock (20.6% vs. 8.8%, p = 0.029). However, there were no differences in all-cause mortality (12.2% vs. 13.1%, p = 0.858) or TTS recurrence (0.0% vs. 3.9%, p = 0.639). After PSM, the previously observed differences were no longer present, with no significant differences in death or recurrences. Conclusions: TTS following pacemaker implantation predominantly presents with greater rates of cardiogenic shock and acute kidney injury, without differences in all-cause mortality or TTS recurrence. After PSM, no differences were found regarding cardiovascular outcomes, suggesting that the physical nature of the trigger could account for the initial differences observed.

Background: Pulmonary embolism (PE) has classically been divided, on the basis of symptom duration, into acute (12 weeks) forms. Subacute PE remains poorly characterised, is frequently underdiagnosed, and is largely absent from randomised trials and dedicated guideline recommendations. Whether the efficacy and safety of catheter-directed therapy (CDT) extend to subacute presentations, in which the thrombus is older, more organised and potentially more adherent, is unknown. We aimed to describe the clinical profile, management and early outcomes of patients with subacute PE selected for CDT within a national interventional registry. Methods: We analysed the National Registry of Catheter-Directed Interventions for the Management of Acute PE (NCT06348459), an investigator-initiated, multicentre registry promoted by the Interventional Cardiology Association of the Spanish Society of Cardiology (ACI-SEC). Subacute PE was defined as a symptom duration >14 days and <12 weeks. Baseline characteristics, echocardiographic variables, biomarkers, invasive pulmonary artery pressures, procedural data and early outcomes were described for the subacute group and set alongside the acute presentations treated in the same cohort. All between-group comparisons are descriptive and exploratory and are not intended to characterise subacute PE beyond this selected population. Continuous variables are median [interquartile range]. Results: Among 447 PE cases treated with catheter-directed therapy, 11 (2.5%) met the criteria for subacute PE and 436 (97.5%) for acute PE. Subacute patients presented with progressive dyspnoea (73%) over a median symptom duration of 21 [18–28] days and infrequent syncope (9%); two patients (18%) fulfilled ESC criteria for high-risk PE and three (27%) required vasoactive amines. Subacute patients showed a right ventricular (RV) basal diameter of 50 [48–52] mm (echocardiographic data available in 7 of 11) and an echocardiographic pulmonary artery systolic pressure of 60 [46–60] mmHg, with a high-sensitivity troponin I of 455 [85–767] ng/L and an NT-proBNP of 1433 [256–1970] pg/mL; corresponding values in acute PE were 47 [44–50] mm, 50 [43–60] mmHg, 237 [97–853] ng/L and 2200 [626–5535] pg/mL. None of the between-group differences reached statistical significance. Catheter-directed therapy achieved 100% procedural success in the subacute group, with invasive systolic pulmonary artery pressure falling from 58 [53–60] to 48 [39–51] mmHg and peripheral oxygen saturation improving from 92% [89–95] to 95% [92–98], with no major periprocedural complications, no circulatory support and no in-hospital deaths. Conclusions: Subacute PE was an infrequent but clinically recognisable presentation among patients treated with catheter-directed therapy, accounting for 2.5% of the cohort and characterised by weeks of progressive symptoms before referral and by a substantial right ventricular and pulmonary pressure load at presentation. Mechanical thrombectomy was safe and effective in this subgroup, with favourable early outcomes comparable to those of acute PE. These hypothesis-generating findings support dedicated study of the diagnosis, risk stratification and interventional management of subacute PE.