Abstract
History and findings: A 60-year-old man underwent a continence-preserving anterior rectal resection for a high rectal carcinoma. After mobilisation on the 5th postoperative day dyspnoea and cyanosis suddenly developed requiring emergency intubation and mechanical ventilation.
Investigations: His heart rate was 160/min, blood pressure 80/50 mmHg, mean pulmonary artery pressure by indwelling catheter was 70 mm Hg. The electrocardiogram had the classical signs of acute right-heart overload. Transoesophageal echocardiography (TOE) demonstrated marked right-heart and pulmonary artery dilatation.
Treatment and course: Despite thrombolytic treatment (bolus of 50 mg r-TPA; one day later bolus of 1 million IU urokinase followed by 100,000 IU/h) a new thromboembolus was seen by TOE to straddle the pulmonary artery bifurcation. After the urokinase 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 dilatation 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.