In a patient with bilateral proximal pulmonary embolus and a clot in the left pulmonary vein who is experiencing hypotension and is unstable, should a Transesophageal Echocardiogram (TEE) be performed first or should thrombectomy be done immediately?

Management of Bilateral Proximal Pulmonary Embolus with Left Pulmonary Vein Clot in an Unstable Patient

In a patient with bilateral proximal pulmonary embolus, clot in the left pulmonary vein, and hemodynamic instability with dropping blood pressure, immediate thrombectomy should be performed without waiting for transesophageal echocardiography (TEE). 1

Rationale for Immediate Thrombectomy

• Patients with high-risk PE (presenting with shock or hypotension) require immediate life-saving intervention, as this is an immediately life-threatening situation 1
• The European Society of Cardiology (ESC) guidelines clearly state that thrombolysis or embolectomy should be considered when a patient with PE is hemodynamically unstable with cardiogenic shock and/or persistent arterial hypotension 1
• Surgical pulmonary embolectomy is the recommended therapeutic alternative in patients with high-risk PE when thrombolysis is contraindicated or has failed 1
• Delaying intervention until cardiogenic shock has fully developed worsens outcomes; early intervention provides better results 2

Diagnostic Algorithm for Unstable PE Patients

In patients with suspected high-risk PE presenting with hemodynamic instability:

1. Bedside transthoracic echocardiography (TTE) should be performed first to assess for RV dysfunction 1
2. If RV dysfunction is present and CT is not immediately available, PE-specific treatment is justified 1
3. In a critically unstable patient where only bedside diagnostic tests are possible, echocardiographic findings of RV dysfunction confirm high-risk PE and emergency reperfusion therapy is recommended 1

Role of TEE vs. Immediate Thrombectomy

• While TEE can be valuable for detecting extrapulmonary thrombi during pulmonary embolectomy, it should not delay life-saving intervention in an unstable patient 3
• TEE can be performed during the thrombectomy procedure rather than before it, as it serves as a guide for the surgeon and monitor of cardiac performance 3
• The ESC guidelines emphasize that systemic hypotension should be corrected promptly to prevent progression of RV failure and death due to PE 1, 4
• In patients with high-risk PE, thrombolysis or embolectomy should be performed without delay to restore pulmonary circulation and reverse right heart failure 1

Management Protocol for Unstable PE Patient

1. Initiate intravenous unfractionated heparin immediately (preferred over LMWH in hypotensive/shock patients) 1, 4

2. Provide oxygen to correct hypoxemia 1, 4

3. Support blood pressure with vasopressors if needed 1, 4

4. Proceed directly to thrombectomy if:

   • Patient has dropping blood pressure/hemodynamic instability 1
   • There is evidence of bilateral proximal pulmonary emboli and left pulmonary vein clot 1
   • Bedside echocardiography shows RV dysfunction 1

5. TEE can be performed during the thrombectomy procedure to guide removal of any additional thrombi 3

Important Considerations

• Aggressive fluid challenge is not recommended in these patients as it may worsen RV function 1
• Dobutamine or dopamine may be used in patients with low cardiac output but normal blood pressure 1
• If thrombectomy is not immediately available, thrombolytic therapy should be considered unless absolutely contraindicated 1
• Catheter-based embolectomy may be considered as an alternative to surgical embolectomy if surgical options are not immediately available 1

Conclusion

In a patient with bilateral proximal pulmonary embolus, clot in the left pulmonary vein, and hemodynamic instability with dropping blood pressure, the evidence strongly supports proceeding directly to thrombectomy without delaying for TEE. The presence of a clot in the pulmonary vein (unusual location) further supports the need for surgical intervention. TEE can be performed during the procedure to guide thrombus removal but should not delay the life-saving intervention.