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Department of Anesthesiology, Perioperative and Pain Medicine, Harvard Medical School, Brigham and Women’s Hospital, Boston, MA Department of Anesthesiology and Intensive Care Medicine, University Hospital, Tübingen, Germany, heltzschig@partners.org
To the Editor:
We read with great interest the excellent case report by Lu et al. describing a patient who experienced a pulmonary embolism (PE) in the perioperative period and was successfully treated with pulmonary embolectomy (1). Rapid and accurate diagnosis was crucial in the management of this patient, as it led to the institution of a successful therapy and a good outcome. The definitive diagnosis of acute PE was obtained by transesophageal echocardiography (TEE) via direct visualization of thrombotic material within the right and left atrium. Accordingly, the authors state that TEE is of great value in the setting of sudden intraoperative cardiovascular collapse and suspected PE.
We fully agree with the authors that TEE is considered a primary diagnostic technique in patients with hemodynamic collapse due to its high availability and outstanding practicality in the perioperative setting (2). It is relatively noninvasive (3) and does not interfere with resuscitation efforts (4). In addition, practice guidelines developed by the American Society of Echocardiography and the Society of Cardiovascular Anesthesiologists highly recommend TEE for diagnosis and management of acute, life-threatening intraoperative hemodynamic collapse (5).
However, the accuracy of TEE for directly diagnosing thromboemboli within the pulmonary artery may be limited. We recently reviewed TEE examinations of 46 patients with known PE and hemodynamic compromise who underwent urgent pulmonary embolectomy. Surprisingly, echocardiographic evidence for the presence of PE was correctly demonstrated only in 46% of all patients. Moreover, the sensitivity for direct visualization of thromboemboli at any specific location was only 26% (6). Therefore, the use of intraoperative TEE to diagnose acute PE via direct visualization may be limited and failure of TEE to directly visualize a PE within the pulmonary artery should not prevent a patient from undergoing further diagnostic testing or therapeutic intervention when a PE is suspected.
In contrast, TEE may be of much greater value for identifying extrapulmonary thromboemboli within the caval veins, right atrium or right ventricle, as presented in this case report. Direct visualization of thromboemboli within the above locations is not only supportive of a diagnosis of PE, but is also critically important for patients who undergo pulmonary embolectomy, as it changes the surgical approach and technique. For example, we recently reported that intraoperative TEE identified intrathoracic, extrapulmonary thromboemboli in 26% of patients undergoing pulmonary embolectomy (n = 50), resulting in an alteration of surgical management in over 10% of patients (7). These findings support the critical role of intraoperative echocardiography during pulmonary embolectomy.
In conclusion, we agree with the authors that TEE should be considered as a primary diagnostic tool and intraoperative monitor in the setting of acute perioperative cardiovascular collapse and suspected PE. However, failure of TEE to directly visualize a PE should not preclude a high-risk patient from undergoing further diagnostic evaluation or receiving a definitive treatment.
References
Department of Anesthesia, Far Eastern Memorial Hospital, Taipei, Taiwan Departments of Surgery and Anesthesiology, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei, Taiwan, canon@ha.mc.ntu.edu.tw
In Response:
We appreciate the comments of Rosenberger et al. (1) about our case report (2) describing the successful rescue of a patient with acute pulmonary embolism and sudden cardiovascular collapse. The TEE is of great diagnostic value in the setting of sudden intraoperative hemodynamic alterations as demonstrated in our report. In addition to the case reported, we present another patient with sudden death with acute massive pulmonary embolism that was rapidly diagnosed by the TEE to be the cause of sudden cardiac arrest in this patient (3). The direct visualization of thrombi in the right atrium helps to rapidly diagnose acute pulmonary embolism. However, the absence of any thrombi within the right atrium, right ventricle, or the pulmonary arteries did not exclude the possibility of pulmonary embolism. In fact, the pulmonary embolism should be suspected in the presence of dilated right atrium and ventricle with poor filled left atrium and ventricle (4).
In conclusion, we agree with Rosenberger et al. that absence of direct visualization of the thrombi in the pulmonary artery should not prevent further diagnostic testing.
References
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