We read with great interest the excellent case report by Espeel et al.1
that describes two patients experiencing pulmonary embolism with additional extrapulmonary thrombi requiring surgical intervention. The positive outcome of both patients corroborates the favorable experience in patients from our institution undergoing surgical pulmonary embolectomy.2
We agree with the authors that intraoperative transesophageal echocardiography is a relatively safe and noninvasive diagnostic modality that allows early detection of intracardiac thrombi. However, we were surprised that the importance of transesophageal echocardiography for the guidance of surgical extraction was not emphasized in this case report. We recently demonstrated that extrapulmonary thromboemboli can be present in the right heart and the vena cava in up to 26% of all patients with massive pulmonary embolism undergoing pulmonary embolectomy.3
Such extrapulmonary thromboemboli may have a significant impact on the surgical procedure, because they may influence cannulation placement and surgical technique during the operation. For example, it may become necessary to perform circulatory arrest in order to evacuate thrombi from the inferior vena cava. Moreover, extrapulmonary thromboemboli that remain unrecognized and are not surgically removed can become the source of recurrent pulmonary embolism.4
Therefore, we believe that intraoperative transesophageal echocardiography is not only an excellent tool for hemodynamic monitoring5
and management of acute right heart failure6
during surgical pulmonary embolectomy, but should also be considered an important diagnostic tool to detect concurrent extrapulmonary thrombi and should guide their surgical extraction.
Martina Nowak, M.D.
Holger K. Eltzschig, M.D.
Prem Shekar, M.D.
Stanton K. Shernan, M.D.
*Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts. firstname.lastname@example.org