- ICH GCP
- US Clinical Trials Registry
- Clinical Trial NCT04996667
Effect of iNO in Patients With Submassive and Massive PE
Study to Evaluate the Role of Inhaled Nitric Oxide (iNO) on Pulmonary Hemodynamics in Patients With Intermediate/Submassive and Massive Pulmonary Embolism (PE)
Study Overview
Status
Intervention / Treatment
Detailed Description
This is a single center study to evaluate patients presenting with imaging confirmed intermediate/submassive or massive pulmonary embolism (PE). The investigators anticipate to enroll a total of 20-25 subjects at Ronald Reagan UCLA Medical Center.
After informed consent is obtained, the subject will proceed under one of two study intervention arms depending on his or her treatment plan. If the patient requires invasive treatment such as interventional thrombectomy or catheter-directed thrombolysis (CDT), the participant will be enrolled in the interventional radiology arm (invasive cohort). If the patient requires non-invasive treatment such as anticoagulation therapy, deep vein thrombosis (DVT) thrombectomy, or inferior vena cava (IVC) filter, the participant will be enrolled in the non-intervention arm (non-invasive cohort).
Interventional Radiology Arm (Invasive Cohort):
The following procedure will be performed:
Interventional radiology (IR) will perform a right heart catheterization (RHC) as part of a planned IR procedure. Patient arrives in the IR suite and is positioned flat with head of bed between flat and 45 degrees. O2 amount and modality, blood pressure, pressor name, dose, and rate will be recorded. If the patient is intubated, the sedation/analgesia drug name(s), dose(s), and rate(s) will be recorded. If the patient is not intubated, name and dose amount of sedation will be recorded. Arterial blood gas will be obtained if an A-line is placed.
Bedside apical 4 chamber view (RV:LV ratio) will be recorded using an ultrasound device, and noninvasive RV data will be obtained with Edwards ClearSight system and Edwards EV1000 clinical platform.
Edwards ClearSight system and Edwards EV1000 clinical platform is a finger probe worn with a supportive forearm strap. Hemodynamic measurements from the finger cuff will be recorded at intervals.
Novel non-invasive methods of estimating stroke volume and associated cardiac output have the potential to revolutionize PE risk stratification and care. Non-invasive blood pressure (NIBP) monitors can even measure stroke volume beat to beat, allowing for continuous evaluation of cardiac function. NIBP systems are typically composed of a finger cuff with an inflatable bladder, pressure sensors, and light sensors. An arterial pulse contour is formed using the volume clamp method of blood pressure measurement combined with calibration and brachial pressure reconstruction algorithms. The stroke volume with each heart beat can be estimated as the area under the systolic portion of the blood pressure curve divided by the afterload. A limitation of using NIBP monitors to measure stroke volume is their relative inaccuracy, as they are calculations of an indirect measurement. However, NIBP monitors¬ may improve clinical care of PE because they allow for assessment of dynamic cardiac changes in real time. Detection of worsening stroke volume in acute PE could inform providers of impending cardiac collapse, and improvement of stroke volume may function as a positive prognostic factor or marker of therapeutic success. Use of NIBP monitors during acute PE to identify clinically significant changes in cardiac function may advance both PE prognostication and management.
The Butterfly iQ+ (one possible ultrasound device which may be used) is a single-probe, whole-body ultrasound device.
After initial measurements, inhaled nitric oxide (iNO) will be administered at 30 ppm for 3 minutes. The same measurements will be obtained/calculated before, during iNO administration, and after iNO has been withheld for 2 minutes.
All major changes in pressures, sedation, vital signs, and major events will be recorded throughout the RHC procedure.
iNO is scheduled to be weaned off post RHC but the IR/anesthesia team may choose to keep the patient on iNO at their clinical discretion. The patient will then proceed to their standard of care IR procedures with planned intervention.
Non-intervention Arm (Non-invasive Cohort):
Vitals including O2 amount and modality, blood pressure, pressor name, dose, and rate will be recorded. If the patient is intubated, the name, dose, and rate of sedation and analgesia will be recorded. If the patient is not intubated, name and dose amount of sedation will be recorded. Arterial blood gas will be obtained if an A-line is placed. Bedside apical 4 chamber view will be recorded (RV:LV ratio) with an ultrasound device, and noninvasive RV data will be obtained with Edwards ClearSight system and Edwards EV1000 clinical platform. This data will be obtained before, during iNO administration, and after iNO has been withheld for 2 minutes.
If a subject initially enrolled in the Non-intervention Arm (Non-invasive Cohort) needs an invasive procedure, they will be removed from the study.
Study Type
Phase
- Phase 2
Contacts and Locations
Study Locations
-
-
California
-
Los Angeles, California, United States, 90095
- Ronald Reagan UCLA Medical Center
-
-
Participation Criteria
Eligibility Criteria
Ages Eligible for Study
Accepts Healthy Volunteers
Genders Eligible for Study
Description
Inclusion Criteria:
- Patient ≥ 18 years of age.
- The patient or patient's surrogate decision maker must understand and sign the informed consent form (ICF).
- Hospitalized (Emergency Room (ER) or inpatient) with:
- Imaging (computed tomography pulmonary angiography (CTPA) or ventilation/perfusion (VQ) lung scan) proven acute pulmonary embolism (PE)
- PE meets the following intermediate risk PE criteria (or massive, see below):
- Troponin > .1 AND
- Imaging (computed tomography (CT) or transthoracic echocardiogram (TTE)) signs of RV compromise (at least 1 of the following):
- RV:LV>1 on TTE or CTPA OR RV dilation (TTE or CTPA OR RV dysfunction on TTE.
- Massive PE
- Intensive care unit (ICU) level of care (Patient moving to ICU, ICU level of care in ER, or currently in ICU)
- Ability to comply with study protocol in investigator's judgement
Exclusion Criteria:
- Pregnancy or breastfeeding
- Inability to administer iNO through current mode of O2 delivery (i.e. BiPAP)
- Active hemoptysis
- Known allergy to iNO.
- Any serious medical condition of lab abnormality that, in the investigator's judgement, precludes the patient's safe participation in the study.
- Methemoglobin reductase deficiency
- Unable to obtain consent or patient or patient surrogate decision maker declines
- Patients already on iNO prior to study enrollment
Study Plan
How is the study designed?
Design Details
- Primary Purpose: TREATMENT
- Allocation: NON_RANDOMIZED
- Interventional Model: PARALLEL
- Masking: NONE
Arms and Interventions
Participant Group / Arm |
Intervention / Treatment |
---|---|
ACTIVE_COMPARATOR: Interventional Radiology Arm (Invasive Cohort)
Interventional radiology (IR) will perform a right heart catheterization (RHC) as part of a planned IR procedure. Bedside apical 4 chamber view (RV:LV ratio) will be recorded using an ultrasound device, and noninvasive RV data will be obtained with Edwards ClearSight system and Edwards EV1000 clinical platform. The Butterfly iQ+ (one possible ultrasound device which may be used) is a single-probe, whole-body ultrasound device. After initial measurements, inhaled nitric oxide (iNO) will be administered at 30 ppm for 3 minutes. The same measurements will be obtained/calculated before, during iNO administration, and after iNO has been withheld for 2 minutes. |
Inhaled nitric oxide (iNO), which is known mainly from the pulmonary hypertension literature for its therapeutic role in pulmonary arterial hypertension, has been proposed as a potential pharmacologic adjunct to standard anticoagulation in acute PE. Inhaled nitric oxide (iNO) will be administered at 30 ppm for 3 minutes. The measurements will be obtained/calculated before, during iNO administration, and after iNO has been withheld for 2 minutes.
Other Names:
|
ACTIVE_COMPARATOR: Non-intervention Arm (Non-invasive Cohort)
Vitals including O2 amount and modality, blood pressure, pressor name, dose, and rate will be recorded.
If the patient is intubated, the name, dose, and rate of sedation and analgesia will be recorded.
If the patient is not intubated, name and dose amount of sedation will be recorded.
Arterial blood gas will be obtained if an A-line is placed.
Bedside apical 4 chamber view will be recorded (RV:LV ratio) with an ultrasound device, and noninvasive RV data will be obtained with Edwards ClearSight system and Edwards EV1000 clinical platform.
This data will be obtained before, during iNO administration, and after iNO has been withheld for 2 minutes.
|
Inhaled nitric oxide (iNO), which is known mainly from the pulmonary hypertension literature for its therapeutic role in pulmonary arterial hypertension, has been proposed as a potential pharmacologic adjunct to standard anticoagulation in acute PE. Inhaled nitric oxide (iNO) will be administered at 30 ppm for 3 minutes. The measurements will be obtained/calculated before, during iNO administration, and after iNO has been withheld for 2 minutes.
Other Names:
|
What is the study measuring?
Primary Outcome Measures
Outcome Measure |
Measure Description |
Time Frame |
---|---|---|
right atrial pressure (RAP)
Time Frame: measured invasively during a right heart catheterization (RHC) before administration of iNO
|
right atrial pressure (RAP) in mmHg
|
measured invasively during a right heart catheterization (RHC) before administration of iNO
|
right atrial pressure (RAP)
Time Frame: measured invasively during a right heart catheterization (RHC) during administration of iNO
|
right atrial pressure (RAP) in mmHg
|
measured invasively during a right heart catheterization (RHC) during administration of iNO
|
right atrial pressure (RAP)
Time Frame: measured invasively during a right heart catheterization (RHC) after administration of iNO
|
right atrial pressure (RAP) in mmHg
|
measured invasively during a right heart catheterization (RHC) after administration of iNO
|
right ventricular pressure (RVP)
Time Frame: measured invasively during a right heart catheterization (RHC) before administration of iNO
|
right ventricular pressure (RVP) in mmHg
|
measured invasively during a right heart catheterization (RHC) before administration of iNO
|
right ventricular pressure (RVP)
Time Frame: measured invasively during a right heart catheterization (RHC) during administration of iNO
|
right ventricular pressure (RVP) in mmHg
|
measured invasively during a right heart catheterization (RHC) during administration of iNO
|
right ventricular pressure (RVP)
Time Frame: measured invasively during a right heart catheterization (RHC) after administration of iNO
|
right ventricular pressure (RVP) in mmHg
|
measured invasively during a right heart catheterization (RHC) after administration of iNO
|
pulmonary arterial pressure (PAP)
Time Frame: measured invasively during a right heart catheterization (RHC) before administration of iNO
|
pulmonary arterial pressure (PAP) in mmHg
|
measured invasively during a right heart catheterization (RHC) before administration of iNO
|
pulmonary arterial pressure (PAP)
Time Frame: measured invasively during a right heart catheterization (RHC) during administration of iNO
|
pulmonary arterial pressure (PAP) in mmHg
|
measured invasively during a right heart catheterization (RHC) during administration of iNO
|
pulmonary arterial pressure (PAP)
Time Frame: measured invasively during a right heart catheterization (RHC) after administration of iNO
|
pulmonary arterial pressure (PAP) in mmHg
|
measured invasively during a right heart catheterization (RHC) after administration of iNO
|
pulmonary capillary wedge pressure (PCWP)
Time Frame: measured invasively during a right heart catheterization (RHC) before administration of iNO
|
pulmonary capillary wedge pressure (PCWP) in mmHg
|
measured invasively during a right heart catheterization (RHC) before administration of iNO
|
pulmonary capillary wedge pressure (PCWP)
Time Frame: measured invasively during a right heart catheterization (RHC) during administration of iNO
|
pulmonary capillary wedge pressure (PCWP) in mmHg
|
measured invasively during a right heart catheterization (RHC) during administration of iNO
|
pulmonary capillary wedge pressure (PCWP)
Time Frame: measured invasively during a right heart catheterization (RHC) after administration of iNO
|
pulmonary capillary wedge pressure (PCWP) in mmHg
|
measured invasively during a right heart catheterization (RHC) after administration of iNO
|
cardiac output (CO) (by Fick and Thermodilution)
Time Frame: measured invasively during a right heart catheterization (RHC) before administration of iNO
|
Cardiac Output (CO) is the amount of blood the heart pumps from each ventricle per minute.
It is usually expressed in litres per minute (L/min).
|
measured invasively during a right heart catheterization (RHC) before administration of iNO
|
cardiac output (CO) (by Fick and Thermodilution)
Time Frame: measured invasively during a right heart catheterization (RHC) during administration of iNO
|
Cardiac Output (CO) is the amount of blood the heart pumps from each ventricle per minute.
It is usually expressed in litres per minute (L/min).
|
measured invasively during a right heart catheterization (RHC) during administration of iNO
|
cardiac output (CO) (by Fick and Thermodilution)
Time Frame: measured invasively during a right heart catheterization (RHC) after administration of iNO
|
Cardiac Output (CO) is the amount of blood the heart pumps from each ventricle per minute.
It is usually expressed in litres per minute (L/min).
|
measured invasively during a right heart catheterization (RHC) after administration of iNO
|
cardiac index (CI) (by Fick and Thermodilution)
Time Frame: measured invasively during a right heart catheterization (RHC) before administration of iNO
|
Cardiac index (CI) is the cardiac output proportional to the body surface area (BSA).
The unit of measurement is litres per minute per square metre (L/min/m2).
|
measured invasively during a right heart catheterization (RHC) before administration of iNO
|
cardiac index (CI) (by Fick and Thermodilution)
Time Frame: measured invasively during a right heart catheterization (RHC) during administration of iNO
|
Cardiac index (CI) is the cardiac output proportional to the body surface area (BSA).
The unit of measurement is litres per minute per square metre (L/min/m2).
|
measured invasively during a right heart catheterization (RHC) during administration of iNO
|
cardiac index (CI) (by Fick and Thermodilution)
Time Frame: measured invasively during a right heart catheterization (RHC) after administration of iNO
|
Cardiac index (CI) is the cardiac output proportional to the body surface area (BSA).
The unit of measurement is litres per minute per square metre (L/min/m2).
|
measured invasively during a right heart catheterization (RHC) after administration of iNO
|
mixed venous O2
Time Frame: measured invasively during a right heart catheterization (RHC) before administration of iNO
|
mixed venous O2 in %
|
measured invasively during a right heart catheterization (RHC) before administration of iNO
|
mixed venous O2
Time Frame: measured invasively during a right heart catheterization (RHC) during administration of iNO
|
mixed venous O2 in %
|
measured invasively during a right heart catheterization (RHC) during administration of iNO
|
mixed venous O2
Time Frame: measured invasively during a right heart catheterization (RHC) after administration of iNO
|
mixed venous O2 in %
|
measured invasively during a right heart catheterization (RHC) after administration of iNO
|
central venous O2
Time Frame: measured invasively during a right heart catheterization (RHC) before administration of iNO
|
central venous O2 in %
|
measured invasively during a right heart catheterization (RHC) before administration of iNO
|
central venous O2
Time Frame: measured invasively during a right heart catheterization (RHC) during administration of iNO
|
central venous O2 in %
|
measured invasively during a right heart catheterization (RHC) during administration of iNO
|
central venous O2
Time Frame: measured invasively during a right heart catheterization (RHC) after administration of iNO
|
central venous O2 in %
|
measured invasively during a right heart catheterization (RHC) after administration of iNO
|
systemic PaO2
Time Frame: measured invasively during a right heart catheterization (RHC) before administration of iNO
|
systemic PaO2 in mmHg
|
measured invasively during a right heart catheterization (RHC) before administration of iNO
|
systemic PaO2
Time Frame: measured invasively during a right heart catheterization (RHC) during administration of iNO
|
systemic PaO2 in mmHg
|
measured invasively during a right heart catheterization (RHC) during administration of iNO
|
systemic PaO2
Time Frame: measured invasively during a right heart catheterization (RHC) after administration of iNO
|
systemic PaO2 in mmHg
|
measured invasively during a right heart catheterization (RHC) after administration of iNO
|
systolic blood pressure (SBP)
Time Frame: measured invasively during a right heart catheterization (RHC) before administration of iNO
|
Systolic Blood Pressure in mmHg
|
measured invasively during a right heart catheterization (RHC) before administration of iNO
|
systolic blood pressure (SBP)
Time Frame: measured invasively during a right heart catheterization (RHC) during administration of iNO
|
Systolic Blood Pressure in mmHg
|
measured invasively during a right heart catheterization (RHC) during administration of iNO
|
systolic blood pressure (SBP)
Time Frame: measured invasively during a right heart catheterization (RHC) after administration of iNO
|
Systolic Blood Pressure in mmHg
|
measured invasively during a right heart catheterization (RHC) after administration of iNO
|
diastolic blood pressure (DBP)
Time Frame: measured invasively during a right heart catheterization (RHC) before administration of iNO
|
Diastolic Blood Pressure in mmHg
|
measured invasively during a right heart catheterization (RHC) before administration of iNO
|
diastolic blood pressure (DBP)
Time Frame: measured invasively during a right heart catheterization (RHC) during administration of iNO
|
Diastolic Blood Pressure in mmHg
|
measured invasively during a right heart catheterization (RHC) during administration of iNO
|
diastolic blood pressure (DBP)
Time Frame: measured invasively during a right heart catheterization (RHC) after administration of iNO
|
Diastolic Blood Pressure in mmHg
|
measured invasively during a right heart catheterization (RHC) after administration of iNO
|
mean arterial pressure (MAP)
Time Frame: measured invasively during a right heart catheterization (RHC) before administration of iNO
|
mean arterial pressure (MAP) in mmHg
|
measured invasively during a right heart catheterization (RHC) before administration of iNO
|
mean arterial pressure (MAP)
Time Frame: measured invasively during a right heart catheterization (RHC) during administration of iNO
|
mean arterial pressure (MAP) in mmHg
|
measured invasively during a right heart catheterization (RHC) during administration of iNO
|
mean arterial pressure (MAP)
Time Frame: measured invasively during a right heart catheterization (RHC) after administration of iNO
|
mean arterial pressure (MAP) in mmHg
|
measured invasively during a right heart catheterization (RHC) after administration of iNO
|
blood pressure (BP) (measured noninvasively)
Time Frame: measured noninvasively before administration of inhaled nitric oxide (iNO)
|
The pressure of the blood in the circulatory system, often measured for diagnosis since it is closely related to the force and rate of the heartbeat and the diameter and elasticity of the arterial walls. Systolic Blood Pressure in mmHg Diastolic Blood Pressure in mmHg |
measured noninvasively before administration of inhaled nitric oxide (iNO)
|
blood pressure (BP) (measured noninvasively)
Time Frame: measured noninvasively during administration of inhaled nitric oxide (iNO)
|
The pressure of the blood in the circulatory system, often measured for diagnosis since it is closely related to the force and rate of the heartbeat and the diameter and elasticity of the arterial walls. Systolic Blood Pressure in mmHg Diastolic Blood Pressure in mmHg |
measured noninvasively during administration of inhaled nitric oxide (iNO)
|
blood pressure (BP) (measured noninvasively)
Time Frame: measured noninvasively after administration of inhaled nitric oxide (iNO)
|
The pressure of the blood in the circulatory system, often measured for diagnosis since it is closely related to the force and rate of the heartbeat and the diameter and elasticity of the arterial walls. Systolic Blood Pressure in mmHg Diastolic Blood Pressure in mmHg |
measured noninvasively after administration of inhaled nitric oxide (iNO)
|
heart rate (HR) (measured noninvasively)
Time Frame: measured noninvasively before administration of inhaled nitric oxide (iNO)
|
The number of heartbeats per unit of time, usually per minute. Measured in beats per minute (BPM) |
measured noninvasively before administration of inhaled nitric oxide (iNO)
|
heart rate (HR) (measured noninvasively)
Time Frame: measured noninvasively during administration of inhaled nitric oxide (iNO)
|
The number of heartbeats per unit of time, usually per minute. Measured in beats per minute (BPM) |
measured noninvasively during administration of inhaled nitric oxide (iNO)
|
heart rate (HR) (measured noninvasively)
Time Frame: measured noninvasively after administration of inhaled nitric oxide (iNO)
|
The number of heartbeats per unit of time, usually per minute. Measured in beats per minute (BPM) |
measured noninvasively after administration of inhaled nitric oxide (iNO)
|
cardiac index (CI) (measured noninvasively)
Time Frame: measured noninvasively before administration of inhaled nitric oxide (iNO)
|
Cardiac index (CI) is the cardiac output proportional to the body surface area (BSA).
The unit of measurement is litres per minute per square metre (L/min/m2).
|
measured noninvasively before administration of inhaled nitric oxide (iNO)
|
cardiac index (CI) (measured noninvasively)
Time Frame: measured noninvasively during administration of inhaled nitric oxide (iNO)
|
Cardiac index (CI) is the cardiac output proportional to the body surface area (BSA).
The unit of measurement is litres per minute per square metre (L/min/m2).
|
measured noninvasively during administration of inhaled nitric oxide (iNO)
|
cardiac index (CI) (measured noninvasively)
Time Frame: measured noninvasively after administration of inhaled nitric oxide (iNO)
|
Cardiac index (CI) is the cardiac output proportional to the body surface area (BSA).
The unit of measurement is litres per minute per square metre (L/min/m2).
|
measured noninvasively after administration of inhaled nitric oxide (iNO)
|
Collaborators and Investigators
Collaborators
Investigators
- Principal Investigator: Rajan Saggar, M.D., University of California, Los Angeles
Publications and helpful links
General Publications
- Summerfield DT, Desai H, Levitov A, Grooms DA, Marik PE. Inhaled nitric oxide as salvage therapy in massive pulmonary embolism: a case series. Respir Care. 2012 Mar;57(3):444-8. doi: 10.4187/respcare.01373. Epub 2011 Oct 12.
- Capellier G, Jacques T, Balvay P, Blasco G, Belle E, Barale F. Inhaled nitric oxide in patients with pulmonary embolism. Intensive Care Med. 1997 Oct;23(10):1089-92. doi: 10.1007/s001340050461.
- Szold O, Khoury W, Biderman P, Klausner JM, Halpern P, Weinbroum AA. Inhaled nitric oxide improves pulmonary functions following massive pulmonary embolism: a report of four patients and review of the literature. Lung. 2006 Jan-Feb;184(1):1-5. doi: 10.1007/s00408-005-2550-7.
- Kline JA, Puskarich MA, Jones AE, Mastouri RA, Hall CL, Perkins A, Gundert EE, Lahm T. Inhaled nitric oxide to treat intermediate risk pulmonary embolism: A multicenter randomized controlled trial. Nitric Oxide. 2019 Mar 1;84:60-68. doi: 10.1016/j.niox.2019.01.006. Epub 2019 Jan 8.
Helpful Links
Study record dates
Study Major Dates
Study Start (ANTICIPATED)
Primary Completion (ANTICIPATED)
Study Completion (ANTICIPATED)
Study Registration Dates
First Submitted
First Submitted That Met QC Criteria
First Posted (ACTUAL)
Study Record Updates
Last Update Posted (ACTUAL)
Last Update Submitted That Met QC Criteria
Last Verified
More Information
Terms related to this study
Additional Relevant MeSH Terms
- Cardiovascular Diseases
- Vascular Diseases
- Respiratory Tract Diseases
- Lung Diseases
- Embolism and Thrombosis
- Embolism
- Pulmonary Embolism
- Physiological Effects of Drugs
- Neurotransmitter Agents
- Molecular Mechanisms of Pharmacological Action
- Vasodilator Agents
- Autonomic Agents
- Peripheral Nervous System Agents
- Protective Agents
- Bronchodilator Agents
- Anti-Asthmatic Agents
- Respiratory System Agents
- Antioxidants
- Free Radical Scavengers
- Endothelium-Dependent Relaxing Factors
- Gasotransmitters
- Nitric Oxide
Other Study ID Numbers
- 21-000569
Plan for Individual participant data (IPD)
Plan to Share Individual Participant Data (IPD)?
Drug and device information, study documents
Studies a U.S. FDA-regulated drug product
Studies a U.S. FDA-regulated device product
product manufactured in and exported from the U.S.
This information was retrieved directly from the website clinicaltrials.gov without any changes. If you have any requests to change, remove or update your study details, please contact register@clinicaltrials.gov. As soon as a change is implemented on clinicaltrials.gov, this will be updated automatically on our website as well.
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