A 43-Year-Old Woman With Intracerebral Hemorrhage and Acute Circulatory Failure.

A 43-year-old woman who was a nonsmoker was being hospitalized because of an intracerebral hemorrhage after a ruptured aneurysm of the posterior communicating artery. The aneurysm was clipped surgically and craniectomy was performed because of intracranial hypertension. On the 16th postoperative day, the patient became comatose and febrile. Cerebrospinal fluid analysis (via a lumbar puncture) yielded Klebsiella pneumoniae. An external ventricular drainage system was placed for intraventricular antibiotic administration,1Tsolaki V. Karvouniaris M. Manoulakas E. et al.Intraventricular CNS treatment with Colistin-Tigecycline combination: a case series.J Crit Care. 2018 Oct; 47: 338-341Crossref PubMed Scopus (19) Google Scholar and the patient was transferred to the ICU for further support. On the 12th day in the ICU, the patient demonstrated circulatory shock. Transthoracic echocardiography (TTE) and subsequent transesophageal echocardiography (TEE) images are shown in Videos 1 and 2 respectively. Informed consent was obtained from the patient’s next of kin. Question 1: On reviewing Videos 1A, 1B, 2 and Figures 1A, 1B showing echocardiography findings, what is the most likely diagnosis?Question 2: How should this patient, who has an absolute contraindication to systemic thrombolysis, be managed? Answer 1: Transthoracic 4-chamber view on shock initiation (Video 1A) depicts signs of acute cor pulmonale and right ventricular (RV) free-wall akinesia with a hyperkinetic apex (McConnell’s sign), an increased size of the RV compared with the left ventricle (LV) and apical disposition of the RV apex over the LV apex. The ratio of the RV end-diastolic area to the LV end-diastolic area is 3.27 (Fig 1A). Video 1B demonstrates the paradoxical motion of the interventricular septum (TTE parasternal short-axis view at the mid-papillary level). The eccentricity index is more than the value of 1 (2.38) (Fig 1B). Video 2A is a TEE view (upper esophageal level) of the large vessels showing a large thrombus located in the right pulmonary artery (Fig 1C). Figure 1D presents additional signs of decreased systolic RV function (tissue Doppler imaging of the peak systolic velocity of the RV at the tricuspid annulus (RV s′), which is decreased severely [0.06 m/sec]). The RV outflow tract velocity time integral (RVOTVTI) measured at the trunk of the pulmonary artery (pulmonic valve stenosis not present) is decreased severely (the mean of three RVOTVTI envelopes [5.6 + 5.6 + 6.4 cm] is 5.86 cm) exhibiting a low cardiac output (Fig 1E). It is worth noting the notch on the descending part of the RVOTVTI envelope, indicating increased pulmonary vascular resistance.2Arkles J.S. Opotowsky A.R. Ojeda J. et al.Shape of the right ventricular Doppler envelope predicts hemodynamics and right heart function in pulmonary hypertension.Am J Respir Crit Care Med. 2011; 183: 268-276Crossref PubMed Scopus (170) Google Scholar The left pulmonary artery cannot be visualized with TEE because the left bronchus lays between the TEE probe and the left pulmonary artery branch. Nonetheless, both pulmonary arteries must be implicated with thrombi presentation for a patient to establish shock.3Findik S. Erkan L. Light R.W. Uzun O. Atici A.G. Akan H. Massive pulmonary emboli and CT pulmonary angiography.Respiration. 2008; 76: 403-412Crossref PubMed Scopus (19) Google Scholar Answer 2: Systemic thrombolysis was contraindicated absolutely. Under TEE guidance, a Swan-Ganz catheter was placed such that the tip ended in the pulmonary artery trunk (Video 2B). A bolus of 8 mg rt-PA-recombinant human tissue type plasminogen activator injection (Actilyse, Boehringer Ingelheim) was administered, followed by a continuous intraarterial infusion of 1 mg/h, with subsequent increase to 2 mg/h, because echocardiographic and clinical variables failed to improve. After a 24-h intraarterial thrombolysis, re-evaluation with TTE (Video 3A) and TEE revealed RV systolic function improvement, but suboptimal thrombus resolution (Table 1, Video 3B). The RV end-diastolic area to LV end-diastolic area ratio is 1.56, which is half of the initial value, indicating both less RV enlargement and less LV compression from the RV (Fig 1A). In the parasternal short axis view at the midpapillary level, a marked reduction in the eccentricity index of 1.22 is evident, whereas the LV has regained its normal spherical shape; no displacement of the interventricular septum toward the LV during systole and diastole is evident, which previously had resulted in the D appearance of the LV (Fig 1B). The tissue Doppler imaging of the RV s′ has increased (0.10 m/s) (Fig 1D). The RVOTVTI remains impaired ((8.2 + 8.8 + 8.8 + 7.9) / 4 = 8.42 cm) (Fig 1E). The notch on the descending part of the RVOTVTI envelope has become smoother, although it is still evident, indicating a decrease in pulmonary vascular resistance (Table 1). However, the patient remained in shock. Thus, it was decided to extend thrombolysis. After a 38-h administration of a total of 42.5 mg Alteplase, RV systolic function improved significantly without any hemorrhagic complications (Fig 1A, C, E). At 48 h, severe enlargement of the RV remained, but the RV end-diastolic area to LV end-diastolic area ratio was 1.35, which is a marked improvement from the first echocardiography examination. TEE revealed only a small part of the thrombus in the right pulmonary artery (Video 3B). The RVOTVTI also increased ((9.6 + 9.6 + 11.3) / 3 = 10.6 cm). Notably, the morphologic features of the notch on the descending part of the RVOTVTI envelope changed (smoother) from Figure E, illustrating the decrease in pulmonary vascular resistance.Table 1Markers of RV Systolic Function, Pulmonary and Systemic Hemodynamics, and Global Tissue Perfusion at the Time of Pulmonary Embolism (Day 0), at 24 H (Day 1), and at 48 H (Day 2) after TEE-Directed, Swan-Ganz-Administered, Low-Dose ThrombolysisVariableDay 0Day 1Day 2RV systolic function RVEDA to LVEDA ratio3.271.561.35 Eccentricity index2.381.22. . . Right ventricular s′, m/s0.060.10. . . TAPSE, cm0.80.81.2 RVOTVTI, cm5.868.4210.6 Stroke volume, mLaMeasured from the product of the flow (RVOTVTI) multiplied by the cross-sectional area of flow (RVOT diameter just proximal to the pulmonic valve from the mid-esophageal right ventricular inflow-outflow tract view [TEE]). The equation used was: π(diameter / 2)2 × RVOTVTI.28.7541.3152 Cardiac output, L/minbMeasured as the product of stroke volume multiplied by the heart rate. Cardiac output was not measured through the Swan-Ganz catheter (with thermodilution) because of the presence of pulmonary embolism.3.14.15.1Right heart pulmonary circulation pressures Pulmonary artery pressure, mm Hg, beats/min (mean)48/30 (36)38/22 (27)33/10 (25) CVP, mm Hg20168 Noradrenaline, μg/kg/min1.330.490.36 Heart rate, beats/min11010098Markers of global tissue oxygenation Lactate, mM6.12.81.8 Urine output, mL/kg/hAnuria0.380.63 SvO2, %576870CVP = central venous pressure; LVEDA = left ventricular end-diastolic area; RV = right ventricle; RVEDA = right ventricular end-diastolic area; RVOTVTI = velocity time integral measured at the level of the right ventricular outflow tract; SvO2 = mixed venous oxygen saturation; TAPSE = tricuspid annular plane systolic excursion; TEE = transesophageal echocardiography.a Measured from the product of the flow (RVOTVTI) multiplied by the cross-sectional area of flow (RVOT diameter just proximal to the pulmonic valve from the mid-esophageal right ventricular inflow-outflow tract view [TEE]). The equation used was: π(diameter / 2)2 × RVOTVTI.b Measured as the product of stroke volume multiplied by the heart rate. Cardiac output was not measured through the Swan-Ganz catheter (with thermodilution) because of the presence of pulmonary embolism. Open table in a new tab CVP = central venous pressure; LVEDA = left ventricular end-diastolic area; RV = right ventricle; RVEDA = right ventricular end-diastolic area; RVOTVTI = velocity time integral measured at the level of the right ventricular outflow tract; SvO2 = mixed venous oxygen saturation; TAPSE = tricuspid annular plane systolic excursion; TEE = transesophageal echocardiography. Massive pulmonary embolism (PE) is a medical emergency and, when associated with shock systemic thrombolytic therapy, is recommended because it improves hemodynamics and RV dilation and dysfunction.4Kearon C. Akl E.A. Ornelas J. et al.Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report.Chest. 2016; 149: 315-352Abstract Full Text Full Text PDF PubMed Scopus (3607) Google Scholar Major bleeding complications occur in up to 20% and intracranial hemorrhage in up to 3% of patients.5Fiumara K. Kucher N. Fanikos J. et al.Predictors of major hemorrhage following fibrinolysis for acute pulmonary embolism.Am J Cardiol. 2006; 97: 127-129Abstract Full Text Full Text PDF PubMed Scopus (127) Google Scholar Catheter-directed thrombolysis (CDT) delivers a thrombolytic agent directly into the pulmonary artery at lower dosages (about one-third) compared with systemic thrombolysis.6Piazza G. Hohlfelder B. Jaff M.R. et al.A prospective, single-arm, multicenter trial of ultrasound-facilitated, catheter-directed, low-dose fibrinolysis for acute massive and submassive pulmonary embolism: the SEATTLE II Study.JACC Cardiovasc Interv. 2015; 8: 1382-1392Crossref PubMed Scopus (578) Google Scholar,7Kucher N. Boekstegers P. Müller O.J. et al.Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism.Circulation. 2014; 129: 479-486Crossref PubMed Scopus (693) Google Scholar The rapid permeation of the thrombolytic agent coupled with local intraclot delivery decreases the risk of bleeding complications.4Kearon C. Akl E.A. Ornelas J. et al.Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report.Chest. 2016; 149: 315-352Abstract Full Text Full Text PDF PubMed Scopus (3607) Google Scholar However, CDT, which is performed in cardiac catheterization laboratories, has been considered mainly for submassive PE. In massive PE, CDT poses the risk of delaying treatment initiation.4Kearon C. Akl E.A. Ornelas J. et al.Antithrombotic therapy for VTE disease: CHEST guideline and expert panel report.Chest. 2016; 149: 315-352Abstract Full Text Full Text PDF PubMed Scopus (3607) Google Scholar Furthermore, Patel et al8Patel N. Patel N.J. Agnihotri K. et al.Utilization of catheter-directed thrombolysis in pulmonary embolism and outcome difference between systemic thrombolysis and catheter-directed thrombolysis.Catheter Cardiovasc Interv. 2015; 86: 1219-1227Crossref PubMed Scopus (77) Google Scholar also reported an increased incidence of renal failure in patients with massive PE receiving CDT. Contrast-induced nephropathy was identified as a possible risk factor, but nonresolving obstructive shock also could be implicated. Therefore, in patients with massive PE and an absolute contraindication for systemic thrombolysis, CDT could become an attractive option. Thrombolytic therapy usually is infused over many hours. Yet, the ideal dose and duration of CDT in massive PE has not been determined. In the Ultrasound Accelerated Thrombolysis of Pulmonary Embolism (ULTIMA) trial enrolling 59 patients with acute main or lower-lobe PE at intermediate risk, ultrasound-assisted CDT was administered using 10 to 20 mg tissue plasminogen activator (tPA); RV dilation improved over 24 h and no major bleeding episode or recurrence of VTE took place.7Kucher N. Boekstegers P. Müller O.J. et al.Randomized, controlled trial of ultrasound-assisted catheter-directed thrombolysis for acute intermediate-risk pulmonary embolism.Circulation. 2014; 129: 479-486Crossref PubMed Scopus (693) Google Scholar The Optimum Duration of Acoustic Pulse Thrombolysis Procedure in Acute Pulmonary Embolism (OPTALYSE PE) trial, which included 101 patients with acute intermediate-risk PE administered tissue plasminogen activator at a maximum dose of 12 mg per lung over 6 h using ultrasound-facilitated CDT. Four patients experienced a major bleeding event.9Tapson V.F. Sterling K. Jones N. et al.A randomized trial of the optimum duration of acoustic pulse thrombolysis procedure in acute intermediate-risk pulmonary embolism: the OPTALYSE PE trial.JACC Cardiovasc Interv. 2018; 11: 1401-1410Crossref PubMed Scopus (244) Google Scholar The Submassive and Massive Pulmonary Embolism Treatment With Ultrasound Accelerated Thrombolysis Therapy (SEATTLE II) study included 150 patients, of whom 31 had massive PE. The duration of drug administration was 24 h, and a total dose of 24 mg of tissue plasminogen activator were administered. Pulmonary artery systolic pressure and the modified Miller index score decreased after the procedure.6Piazza G. Hohlfelder B. Jaff M.R. et al.A prospective, single-arm, multicenter trial of ultrasound-facilitated, catheter-directed, low-dose fibrinolysis for acute massive and submassive pulmonary embolism: the SEATTLE II Study.JACC Cardiovasc Interv. 2015; 8: 1382-1392Crossref PubMed Scopus (578) Google Scholar In patients in the ICU, PE is common despite pharmacologic thromboprophylaxis, the use of intermittent pneumatic compression stockings, or both. Multiple factors such as the underlying illness, thrombocytopenia, and recent surgical procedures may preclude the use of systemic thrombolysis in certain patients with massive PE. This patient showed at presentation an absolute contraindication for systemic thrombolysis for various reasons (intracerebral hemorrhage, recent ruptured cerebral aneurysm, brain surgery, presence of an external ventricular drainage catheter). Yet, she received CDT at double the dose compared with the literature-reported dose, fortunately without any hemorrhagic complications. Swan-Ganz CDT has been reported in patients in the ICU at a maximum dose of 20 mg over a period of as long as 20 h.10Jha A. Ahmed M. An emerging use of the Swan-Ganz catheter: pulmonary artery catheter delivered thrombolysis in massive pulmonary embolism.Catheter Cardiovasc Interv. 2020; 96: 728-729Crossref PubMed Scopus (1) Google Scholar,11Karahaliou A. Papathanasiou A. Andrianopoulos I. et al.Thrombolysis through a Swan-Ganz catheter in two patients with high-risk pulmonary embolism and absolute contraindication for systemic thrombolysis.Hellenic J Cardiol. 2018; 59: 296-297Crossref PubMed Scopus (3) Google Scholar In the current patient, hemodynamic (systemic, Swan-Ganz-derived) (Table 1) and echocardiographic variables presented suboptimal improvement over the first 24 hours; thus, it was decided to extend the duration of thrombolysis. We believe that localized administration of a low-dose thrombolytic agent (half of the systemic thrombolysis dose) within an extended time frame (48 h instead of 2 h) successfully treated the patient without any hemorrhagic complications. TEE proved to be a valuable tool for the management of this patient because it provided the diagnosis of massive PE (Video 2A) and also guided the treatment (Video 2B). Transportation of critically ill patients with severe shock to the radiology department often is not feasible, and therefore, TTE and TEE are invaluable bedside tools. Moreover, serial daily TEE examinations (Video 3A, 3B, Fig 1) facilitated the monitoring and led to the decision to extend the administration of localized thrombolysis. TEE also directed the optimal placement of a Swan-Ganz catheter (Video 2B) at the end of the main pulmonary tract, so that the thrombolytic agent could be delivered to both pulmonary arteries. In massive PE, bilateral pulmonary emboli must be present for obstructive shock to occur. The severity of the patient’s hemodynamic status precluded the performance of CT scan pulmonary angiography; hence, extension of the thrombus in the left pulmonary artery could not be excluded. This patient demonstrates that, in those with obstructive shock in a critical care setting, TEE was more valuable than CT scan imaging because it facilitated the diagnosis, guided the optimal location of the Swan-Ganz catheter to administer localized thrombolysis, and guided treatment decisions through serial evaluations of the results. TEE-guided, Swan-Ganz-administered, extended low-dose thrombolysis (less than systemic but more than the unstandardized CDT dose) may be considered for nontransferable patients in the ICU with massive PE and increased hemorrhagic risk. See Narration Video for a detailed explanation of Video 1, Video 2, Video 3. 1.Echocardiography is an invaluable tool in patients in the ICU for the differential diagnosis of shock.2.TEE can facilitate the diagnosis of massive PE in nontransferable patients in the ICU and can monitor the results of thrombolytic treatment.3.TEE-guided Swan-Ganz placement can deliver localized thrombolytic therapy successfully in critically ill patients with massive PE and an absolute contraindication for systemic thrombolysis.4.TEE may guide the decision for extended CDT in patients with echocardiographic findings and clinical signs of nonresolving shock. Financial/nonfinancial disclosures: None declared. Other contributions: The authors thank Elena Koushiappi, MD, pulmonologist-intensivist at the General Hospital of Nicosia, Cyprus, and Sofia Litrokapi for editing the manuscript. CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met. Additional information: Videos for this case are available under "Supplementary Data." eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIyYjEwN2MwNzU4ZDYxMDdjYjc3OWI1OGEwMzc5ZGU2NCIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjk0NDcyOTA4fQ.Y9TP2MM9e8xrWHz1MbpOk5OAj1qHUk6qwy1rSudURvCfD36Spb42XAx9UqXTz0ESI-qkS783Dv1RcZlbZ44rbint3sw25HDBymeJGoQghp6eq7ln4Vytk4-SA4k8cRT2HhaeMnKFxyTldZIxoK6pAqdDDmNBgng-4uZ2-BeFqwxRiMkTLGpjq9XvDAlTNCtkOnCpeRtzeOFdMj56GyzGp302USyS84POVLCqwCrJBdkaOrSd6xzL7V5-TGdOnwLNSswJFePPE3OmcExSajQLGqDqAhyWk_3h4SXbeE54owDZ_G6e03JAM5Piw5QPKF7iKUBcH4gr5RL5qTzSlDp-tg Download .mp4 (110.89 MB) Help with .mp4 files Narration VideoeyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJkOTQyM2UzNDM3ZDYwN2Y2MWRlNmU4ZGFmNDI1ZDIyNiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjk0NDcyOTA4fQ.FLaIAVd0DV8Yh0kC0UCeDTPsI-Ik966yWhSwg6y0d8d4AwMBYAjresxbaDC5v9FBoHeDhijfVzXfuR2xQb4saPDXXY4B0cHlfHPdNUmhmQjFfJmgTDgbXm9E1zo9lYr3i8jIZtuTfStkU4rPLIyafjLXS1ik0tRMcZPpxv0AGMFUr7qH0-emCyGTqKTWTYblTuR7V-DTPUVMwV0oJgFywh2pwmYsp0IWvPNkHzekXuKo5_scdfqg_C3tqAKmi-cMlRpkThtTXnvo5ohYhJcWRpzqFdX1yWCiw8vVyo6d1AS5yDrRAdD74345Mw-Qm1SJ2ifyu94K8RoHIxhQtZyB9Q Download .mp4 (0.29 MB) Help with .mp4 files Video 1A, Transthoracic 4-chamber view on shock initiation depicting signs of acute cor pulmonale, including right ventricle (RV) free-wall akinesia with a hyperkinetic apex (McConnell’s sign). Note the increased size of the RV over the left ventricle (LV) and the apical disposition of the RV apex over the LV apex (RV end-diastolic area to LV end-diastolic area ratio, 3.27). B, Transthoracic parasternal short-axis view at the mid-papillary level showing paradoxical septal motion.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIyMjQ3MGQ0OWExNDFkOTM0MDY1MjA0Y2U3OTgxYTUyMiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjk0NDcyOTA4fQ.TlCm2vmjMbwbJ56u4ku92s2XgazARNcKlAwtPwqyr5RUWX6h9_nfUGvLY2xortcvy8wAOb9DUIFOyMF1APe8S2vEp6UcZcdBRSSCYFzQqukXtVYSAIGaLd-df7g0alqEnf2EQlr1EeWnRivDibwoxo_EHbHtweZpOM5gC6GmEw8XTukLu478PJn5nqZFbNmsrh8q3TVxcccas84Cs4ycQCqx_qDm5e3Mr3Ln4WscNh3vAON9mqj9M1rXbaJ6Ry6XHHlRocrY4rhlstoMrCyHf0llRUInUJA4lf2OP5gZWSuFadxfOSTjDIIwX2yuIhjF3_qgOksiPheBsFK-CnVivw Download .mp4 (0.29 MB) Help with .mp4 files Video 1A, Transthoracic 4-chamber view on shock initiation depicting signs of acute cor pulmonale, including right ventricle (RV) free-wall akinesia with a hyperkinetic apex (McConnell’s sign). Note the increased size of the RV over the left ventricle (LV) and the apical disposition of the RV apex over the LV apex (RV end-diastolic area to LV end-diastolic area ratio, 3.27). B, Transthoracic parasternal short-axis view at the mid-papillary level showing paradoxical septal motion.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJiNGZiOTBjMjE1ZjViZWNmZWUwNmZiMzBlYzZlZTdjNSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjk0NDcyOTA4fQ.dLcLd60MX8cPMD4dtWB7ngXc1D9u_O9F-ZdFiP2LqureqplRW70aeTbpgTKFUMmjLunn0DXuhLm2WNmxIhiKVkkEW42BhkhE2uapfO2mOyTH-Gx4AqcmMVKqG3xD1GECVo7BiVqzG8LEC29-qoIuXjSyngiYUFh2Xp5erGSbrGKZfctCUwHIrn5OeIaU91PVu9HRn8oTVXaRrziu6vy8HFaKUISa8jO70hhtfEYZLL4ZZ9hVdUmJYxFigGvkx7HeywhW6y8j4FzWfQGcBFzm2uhgYtaLo38AmiQDX8ZPT8U2wv7B-YpIesVYoEyl6WFj4qdz19DCF9NYkPe9euAkpA Download .mp4 (1.91 MB) Help with .mp4 files Video 2A, Transesophageal view (upper esophageal view) of the large vessels showing a large thrombus located in the right pulmonary artery. The left pulmonary artery cannot be visualized with transesophageal echocardiography (TEE) because the left bronchus lays between the TEE probe and the left pulmonary artery branch. Yet, we hypothesize that thrombi are present in the left arterial bed; as in patients with pulmonary embolism and obstructive shock, emboli are present in the pulmonary arteries, pulmonary branches, or both. B, TEE-guided Swan-Ganz placement just before the bifurcation of the pulmonary artery trunk and instillation of thrombolytic therapy (bolus-dose echo-contrast material flowing in the trunk).eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJlZTY4N2JmNWUyMzNjMmY3YjkzMTVjN2Q2MGFjN2NjMiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjk0NDcyOTA4fQ.nn3PNlFia-KET5E67XZXWg0wKqyI4dci0VJcrZqo2sMOEzzIdRgYLZGIW0FsAslaZciOgz_HOdey-zjfssn7iXKgZm3tZCcqO1_KgGXvxAiT4pmffgJfc2awSnCtoOQSAILEJYE8GpefOFIk73dLYE_4zySSHgNOtc8ANK9yOzsvHALKuOmr043i27-WVO7bog91jNoB2qWkqImIRxGGyR7EyYfijWUH-nb2Z6C1TB_uV-WvYKjRYb-Gyoq77QmPK56kMq31BYsw_B-In6DxwLdQ-NtLyu9i00cV_wJ3kD-Lc8Cts71-tMb6nZ-4gdVLA4gas4EpQXQH7_vuPNks2w Download .mp4 (0.99 MB) Help with .mp4 files Video 2A, Transesophageal view (upper esophageal view) of the large vessels showing a large thrombus located in the right pulmonary artery. The left pulmonary artery cannot be visualized with transesophageal echocardiography (TEE) because the left bronchus lays between the TEE probe and the left pulmonary artery branch. Yet, we hypothesize that thrombi are present in the left arterial bed; as in patients with pulmonary embolism and obstructive shock, emboli are present in the pulmonary arteries, pulmonary branches, or both. B, TEE-guided Swan-Ganz placement just before the bifurcation of the pulmonary artery trunk and instillation of thrombolytic therapy (bolus-dose echo-contrast material flowing in the trunk).eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIzM2JjY2Q0OGM2MTFjZjAyNmJiNjJhOTNhZWVlYzQyMyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjk0NDcyOTA5fQ.hjCteCjX4EIWBalDS6R856j-AzL7S7nydlu9kNcXVPQSbB_ZmUuBex1YZCPKBDTlRBOE94A9kA9mMnUo3qOpkWBOwEwur-HwlxuPa470WPlovr139Z05opIsSpMvbB1epjcoBTmM7So7B6jvtFfFXxdT0X5C4CE-1TkWJ2IrNGiDpdX7RFfilB5k6mQDqmYUPIWEJcK2QbFIRT2546QFTTD_s806f-vBXTkgTQCqL5FygwE9aWCTOdhifqM_176I4xKv6pE_UFvbEsc2sticSuQF8ffwHS8Jloie01QwHR4peiCrQBVPYNXHH4615CgbLcyUTzuqDn0WrMY8kE5kYg Download .mp4 (1.42 MB) Help with .mp4 files Video 3A, Transesophageal echocardiography (TEE) examination 24 h after initiation of thrombolysis showing partial resolution of the thrombus in the right pulmonary artery. B, TEE examination 48 h after initiation of thrombolysis showing that the largest part of the thrombus has resolved.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIxMGQwZWZlMjAwMGRmZmRkYmM3Njk3Y2YzMGNiNmI0YyIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjk0NDcyOTA5fQ.h0LRF2tKCNfX9MUAbmRwpN6LeWx4DDIxKcCq_m-9HTKX_8GrBKCISprumUy8uRI0OVHKDRGWHXXXWiPg_XOKcf7tRHiCYSI1-Or2jGuqgxJdUK_Hdxt8ewx8V-wgLXNN7sNY-WjRiv30LykrBcv0uAUSd8kIqUzp0to6o6pqDlc5V5sZCBat8ezgFk7j0-unI6Eej6YVZaSrTkiefmdz0Q4RT-jRUiLfXKT0bs0npRwNfgyWoSSCkZdCvcbhAejmJZLKPcSXvD7bWVYkQ-uknzdtMzEVNywLPpH-R5Kt6se2iI8m8yzkg54XF05C3zoUvQeCuR1DIVYMn0bVwqv3Cw Download .mp4 (0.61 MB) Help with .mp4 files Video 3A, Transesophageal echocardiography (TEE) examination 24 h after initiation of thrombolysis showing partial resolution of the thrombus in the right pulmonary artery. B, TEE examination 48 h after initiation of thrombolysis showing that the largest part of the thrombus has resolved.