MASSIVE INTRAOPERATIVE PULMONARY-EMBOLISM - DIAGNOSIS AND CONTROL OF EFFICACY OF EMBOLECTOMY BY TRANSESOPHAGEAL ECHOCARDIOGRAPHY

Massive intraoperative embolism is a life-threatening condition that m ay lead to immediate death. Important for the survival of the patient are rapid diagnosis and prompt surgical embolectomy. Case report. Nine teen days after a traffic accident, a 67-year-old patient who had comp lex ligamentous injuries was operated upon on both knees during genera l anaesthesia. The operation progressed uneventfully for the first 30 min when the patient's systolic blood pressure became slightly unstabl e and decreased to 85 mm Hg despite administration of ephedrine and in fusion of hetastarch. This was followed 30 min later by an immediate d rop to values that were undetectable on an oscilloscope. The pulse oxi meter no longer detected a signal at the finger-tip and the end-tidal CO2 decreased to 1 kPa (7.5 mm Hg). To confirm the diagnosis of an acu te pulmonary embolism, we performed transoesophageal echocardiography (TEE) and found a large amount of free-floating material in the right atrium, a dilated and hypokinetic right ventricle, and a collapsed lef t ventricle (Fig. 1a). Embolectomy was immediately started using the i nflow-occlusion technique supported by cardiopulmonary bypass (CPB). A ll emboli were removed from the right atrium and pulmonary artery (Fig . 1b). During closure of the sternotomy, heart function was monitored by TEE and we again noted large emboli in the right atrium (Fig. 1c). To remove these, we reinstated CPB and then placed an inferior vena ca va filter. The final TEE control showed free heart chambers with good contractility (Fig. 1 d). The postoperative course of the patient was without complications, and he left the hospital 41 days after the oper ation without sequelae from the massive pulmonary embolism. Conclusion . Intraoperative diagnosis of acute pulmonary embolism with shock is d ifficult. Clinical signs are unspecific and are rarely present during general anaesthesia. ECG changes may occur only later. As a result of the persistent shock, the pulse oximeter no longer works properly and the decrease in end-tidal CO2 may be explained by other reasons such a s low cardiac output from a myocardial infarction. In this situation, TEE is a very useful method for quickly confirming the diagnosis of ma ssive pulmonary embolism. In addition, we have shown that TEE is effec tive in detecting new emboli after an embolectomy. We conclude that TE E is a life-saving diagnostic tool that is useful for confirming acute pulmonary embolism and controlling the efficacy of embolectomy.