TRANSESOPHAGEAL ECHOCARDIOGRAPHIC MONITOR ING IN FULMINANT PULMONARY-EMBOLISM

History and findings: A 60-year-old man underwent a continence-preserv ing anterior rectal resection for a high rectal carcinoma. After mobil isation on the 5th postoperative day dyspnoea and cyanosis suddenly de veloped requiring emergency intubation and mechanical ventilation. Inv estigations: His heart rate was 160/min, blood pressure 80/50 mmHg, me an pulmonary artery pressure by indwelling catheter was 70 mm Hg. The electrocardiogram had the classical signs of acute right-heart overloa d. Transoesophageal echocardiography (TOE) demonstrated marked right-h eart and pulmonary artery dilatation. Treatment and course: Despite th rombolytic treatment (bolus of 50 mg r-TPA; one day later bolus of 1 m illion IU urokinase followed by 100,000 IU/h) a new thromboembolus was seen by TOE to straddle the pulmonary artery bifurcation. After the u rokinase dosage had been raised to 200,000 IU/h TOE on the 6th day no longer showed the embolus and documented a reduction in right-heart di latation associated with improved haemodynamics. Conclusion: TOE is an ideal method for the rapid diagnosis and for monitoring the response to treatment of fulminant pulmonary arterial embolism. As it can also diagnose thromboembolism without significant haemodynamic consequences it is possible to adjust fibrinolytic treatment accordingly.