Impact of the Incidental Diagnosis of Clinically Unsuspected Central Pulmonary Artery Thromboembolism in Treatment of Critically III Patients: Conclusion

Furthermore, Wittlich et al and Ritto et al emphasized that the TEE diagnosis of central PE may avoid further time-consuming invasive measures to institute therapy without delay. Similar to our series, incidental diagnosis of PE by TEE performed for other reasons has been reported. This report and our study clearly demonstrate and support the well-recognized fact that PE can coexist with other acute cardiopulmonary disorders. The magnitude of these comorbid disorders often leads to the underrecognition of PE. In addition, TEE also provided important anatomic and physiologic information. Eleven of 14 patients had right heart strain indicating that the thromboemboli seen in the pulmonary artery are clinically significant. This finding is similar to that reported by Kasper et al using TTE and Wittlich et al using TEE in patients documented to have PE. This also suggests that in patients presenting with either clinically suspected PE or findings of acute cardiopulmonary disorders, and TTE is not feasible or poor, TEE allows reliable assessment of right ventricular anatomy and physiology. If there is TEE evidence for right heart strain, this increases the suspicion for coexisting PE. Transesophageal echocardiography also demonstrated patent foramen ovale in 3 of 12 patients providing an explanation for hypoxemia (Table 2).
The impact of TEE diagnosis of unsuspected PE in critically ill patients has not been well established. Based on the diagnosis of PE by TEE, treatment was changed in all 14 patients. Ten of 14 patients recovered clinically and were discharged from the hospital while 4 patients died despite appropriate treatment. Mortality is high (30 percent) in patients in whom PE is not recognized and treatment is not initiated, whereas outcome significantly improves in patients treated for PE.2 Our data indicate that changing the treatment after the incidental detection has had a favorable outcome. In our patients, although there was other supportive evidence for PE, ie, risk factors and right heart strain by TTE, it was only after the incidental direct visualization of thromboemboli by TEE that treatment was changed resulting in a favorable outcome.

We conclude that clinically unsuspected incidental thromboemboli in the central pulmonary arteries are not uncommon, especially in patients with acute cardiopulmonary symptoms. Establishing a prompt diagnosis in these patients will favorably affect short-term outcome. The presence of risk factors for PE along with right heart strain should alert the physician to suspect PE as a sole or coexisting morbidity in patients presenting with acute cardiopulmonary symptoms. If and when TEE is performed in patients with acute cardiopulmonary symptoms and evidence of right heart strain, the physician should evaluate the main pulmonary artery and its branches for the presence of central pulmonary artery thromboemboli.

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