Accepted Manuscript Successful surgical pulmonary embolectomy for massive perinatal embolism after emergency cesarean section Sébastien Colombier, MD, Lars Niclauss, MD PII:
S0890-5096(15)00495-1
DOI:
10.1016/j.avsg.2015.04.066
Reference:
AVSG 2413
To appear in:
Annals of Vascular Surgery
Received Date: 12 January 2015 Revised Date:
19 February 2015
Accepted Date: 1 April 2015
Please cite this article as: Colombier S, Niclauss L, Successful surgical pulmonary embolectomy for massive perinatal embolism after emergency cesarean section, Annals of Vascular Surgery (2015), doi: 10.1016/j.avsg.2015.04.066. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
Successful surgical pulmonary embolectomy for massive perinatal embolism after emergency cesarean
RI PT
section
Sébastien Colombier MD*
SC
Lars Niclauss MD*
M AN U
*Department of Cardiovascular Surgery, University Hospital of Lausanne (CHUV), Switzerland
Corresponding author: Lars Niclauss
TE D
Department of Cardio-vascular Surgery University Hospital of Lausanne
EP
46, rue du Bugnon
AC C
CH-1011 Lausanne, Switzerland
Tel: +41 (0)79 5561690 / Fax: +41 (0)21 3142278 E-mail address: [email protected] Funding: None
ACCEPTED MANUSCRIPT 2
Abstract:
RI PT
Pregnant women are exposed to an increased risk for developing pulmonary embolism (PE), a main cause for maternal mortality. Surgical pulmonary embolectomy is one important therapeutic and potential lifesaving armamentarium, considering pregnancy as a relative contraindication for thrombolysis. We present a case of a 36 year old woman with massive bilateral PE after emergent caesarean delivery, requiring
SC
reanimation by external heart massage. The onset of massive intra-uterine bleeding contraindicated thrombolysis and emergency surgical pulmonary embolectomy, followed by a hysterectomy, were
M AN U
preformed successfully. Acute surgical pulmonary embolectomy may be an option in critically diseased high risk patients, requiring a multi team approach, and should be part of the therapeutic armamentarium
AC C
EP
TE D
of the attending cardiac surgeon.
ACCEPTED MANUSCRIPT 3
Background: Pulmonary embolism (PE) in pregnant women is rare; however it is a severe disease and one major cause for maternal death in the developed world (1,2). Venous thrombo-embolism describes the frequent
RI PT
association of the (often silent) deep-vein thrombosis and PE. The incidence of venous thromboembolism is significantly higher during pregnancy and emergency caesarean delivery is one major risk factor in the early postpartum period (1,3,4). A reduced venous flow in the legs has been documented
SC
during the last trimester of gestation and lasts probably until 6 weeks after deliver (1). The clinical classification of the severity of acute PE distinguishes the massive, high-risk PE (shock or persistent
M AN U
arterial hypotension) from the sub-massive, not high-risk PE (without these symptoms), a differentiation with major impact on estimated in hospital mortality rate and on recommended medical care (5). In the former, urgent thrombolysis and (if contraindicated) surgical pulmonary embolectomy, will be potential live saving treatment strategies in patients with severe hemodynamic compromise. PE during pregnancy or after caesarean delivery may contraindicate thrombolysis (5). Several case reports suggest that prompt
TE D
diagnosis and a multidisciplinary approach, including surgical pulmonary embolectomy, may permit survival of these high risk patients (6,7). We present a case of successful surgical embolectomy for
Case presentation:
EP
massive pulmonary emboli during the immediate postnatal period after emergency caesarean section.
AC C
A 36 year old pregnant and healthy woman (BMI of 24 kg/m2, no history of thrombo-embolism) was admitted to the obstetrics department in her 36 week of gestation for pathologic cardiotocography after spontaneous membrane rupture. Emergency caesarean delivery was realized under local (epidural) anesthesia without intra-operative complication and a healthy baby was born. Half an hour after admission to the anesthetic recovery room, the patient became hemodynamically instable, presenting severe bradycardia and hypotension, followed by cardiac arrest requiring immediate cardio-respiratory resuscitation during five minutes. External cardiac massage, ventilation after emergency intubation and
ACCEPTED MANUSCRIPT 4
cardiac ionotropic drug support allowed a transitory stabilization. First arterial blood gas analysis after reanimation showed a global respiratory insufficiency and acidosis (pH 7.03, lactate 6.9 mmol/l, PO2 40 mmHg, PCO2 63 mmHg, SO2 85%). Echocardiography revealed a severe right heart dysfunction and
RI PT
massive dilatation, with an akinetic right ventricular (RV) free wall and a normal contracting RV apex (positive McConnel sign) and acute PE was the suspected main diagnosis (Fig.1) (8). Hemodynamic instability required increasing ionotropic drug support. The patient presented an active vaginal bleeding
SC
after cardiac reanimation and direct ultrasound examination confirmed intra-uterine hemorrhage. CT scan of the lungs confirmed the diagnosis of PE and showed an occlusion of the segmental and sub-segmental
M AN U
pulmonary arteries; however the main arteries were free, probably due to cardiac massage and consecutively thrombi pushing and fragmentation (Fig.2). Intra-uterine tamponade using a Bakri® postpartum balloon was realized for temporary hemostasis and the patient was transferred to the OR for emergency surgical pulmonary embolectomy. After median sternotomy, aortic and bi-caval cannulation, pulmonary embolectomy was performed through a longitudinal pulmonary arteriotomy under cardiac
TE D
arrest. Gentle squeezing of both lungs (after both pleural spaces had been widely opened) enabled a backwards pushing of large thrombi in both main pulmonary arteries and subsequent removal (Fig.3). The patient got off bypass with persistent right heart dysfunction but with normal blood oxygenation. After
EP
sternal closure, hysterectomy was performed due to ongoing bleeding from the uterus. A vena cava filter was inserted via the common femoral vein at postoperative day one. Laparotomy with initial abdominal
AC C
packing was closed two days later and continuous postoperative recovery in the ICU unit allowed extubation at postoperative day four. The patient left hospital ten days later with good general postoperative recovery, a moderate right heart dysfunction (according to the guidelines from the American Society of Echocardiography) and a persistent pulmonary hypertension, with a pulmonary arterial pressure (PAP) of 30 mmHg, at echocardiography (9). A systematic oral anticoagulation therapy by warfarin has been started during hospitalization and maintained for at least three months postoperatively.
ACCEPTED MANUSCRIPT 5
Follow up at three months showed a persistent right ventricular dilatation and moderate dysfunction (9). Patient complained a persistent slight dyspnea at physical effort (NYHA II). Cardiac catheterization
RI PT
showed a normal systolic /diastolic PAP of 18/7 mmHg (corresponding to a mean PAP of 11 mmHg).
Discussion:
SC
Pregnant women are exposed to an increased risk for developing PE, a main cause for maternal mortality (1,3). To ensure survival in massive PE, rapid diagnosis and multidisciplinary approaches, including
M AN U
surgical strategies, should be mandatory. Surgical pulmonary embolectomy is one important therapeutic and potential life-saving armamentarium to treat these patients, considering pregnancy as a relative contraindication for thrombolysis (5). Several case reports have documented successful surgical interventions in these circumstances (6,10). We present a case of a perinatal massive PE immediately after emergent caesarean section. Main contraindication for thrombolytic therapy, in this
TE D
hemodynamically instable patient presenting severe right heart dysfunction, was given due to severe intrauterine post caesarean bleeding. Causal factors for a probably ongoing, and finally, after cardiac reanimation, massive bleeding, were, as well as a non compaction of the dilated and (after a caesarean)
EP
surgically injured uterus, an important venous hypertension due to congestive right heart failure. Severe cardiogenic shock and the onset of beginning concomitant disseminated intravascular coagulation in a
AC C
comatose and highly instable patient, were further contributing factors maintaining the bleeding. To our knowledge, this is the second description of a successfully treated patient having undergone emergency surgical pulmonary embolectomy in these clinical circumstances (11). Although caesarean section is a major risk factor for developing PE, diagnosis and treatment algorithms remain challenging. Echocardiography is a rapidly available diagnostic tool in order to identify right heart dysfunction and increased pulmonary pressure as indirect signs (8). Direct visualization of thrombi in the pulmonary artery tree may also be possible (11). In the present case, successful cardiac resuscitation for transitory
ACCEPTED MANUSCRIPT 6
stabilization of the patient required external heart massage. Therefore blood clots initially located in the main central pulmonary arteries had probably been pushed more distally (Fig 2). Ct scan in cases of nonvisualization of pulmonary emboli at echocardiography seems to be crucial for the correct diagnosis and
RI PT
to evaluate the feasibility of the surgical approach. If thrombi occlude the segmental branches of the lungs susceptible for acute right heart failure, surgical removal should be envisaged.
SC
Conclusion:
M AN U
Guidelines indicate thrombolytic therapy as the treatment of choice for PE in high risk patients (cardiogenic shock due to massive PE). If contraindications do exist, acute pulmonary embolectomy is indicated as a reserve strategy (5). The present case shows that surgery has its role in complicated emergency situations requiring a multi team approach. Acute surgical pulmonary embolectomy may be an option in critically diseased high risk patients and should be part of the therapeutic armamentarium of the
AC C
EP
TE D
attending cardiac surgeon.
ACCEPTED MANUSCRIPT 7
RI PT
References:
Marik PE, Plante LA. Venous thromboembolic disease and pregnancy. N Engl J Med. 2008;359:2025-33. Berg CJ, Chang J, Callaghan WM, Whitehead SJ. Pregnancy-related mortality in the United States, 1991-
SC
1997. Obstet Gynecol. 2003;101:289-96.
M AN U
Simpson EL, Lawrenson RA, Nightingale AL, Farmer RD. Venous thromboembolism in pregnancy and the puerperium: incidence and additional risk factors from a London perinatal database. BJOG. 2001;108:56-60.
Jacobsen AF, Skjeldestad FE, Sandset PM. Ante- and postnatal risk factors of venous thrombosis: a
TE D
hospital-based case-control study. J Thromb Haemost. 2008;6:905-12.
Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N et al. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)
EP
Endorsed by the European Respiratory Society (ERS). Eur Heart J. 2014;35:3033-73.
AC C
Saeed G, Möller M, Neuzner J, Gradaus R, Stein W, Langebrake U et al. Emergent surgical pulmonary embolectomy in a pregnant woman: case report and literature review. Tex Heart Inst J. 2014;41:188-94. Taniguchi S, Fukuda I, Minakawa M, Watanabe K, Daitoku K, Suzuki Y. Emergency pulmonary embolectomy during the second trimester of pregnancy: report of a case. Surg Today.2008;38:59-61. Haller EP, Nestler DM, Campbell RL, Bellamkonda VR. Point-of-care ultrasound findings of acute pulmonary embolism: McConnell sign in emergency medicine. J Emerg Med. 2014;47:e19-21.
ACCEPTED MANUSCRIPT 8
Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the
RI PT
European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010 ;23:685-713.
Waldman M, Sheiner E, Sergienko R, Shoham-Vardi I. Can we identify risk factors during pregnancy for
SC
thrombo-embolic events during the puerperium and later in life? Matern Fetal Neonatal Med. 2014;31:15.
M AN U
Wei J, Yang HS, Tsai SK, Hsiung MC, Chang CY, Ou CH et al. Emergent bedside real-time threedimensional transesophageal echocardiography in a patient with cardiac arrest following a caesarean
AC C
EP
TE D
section. Eur J Echocardiogr. 2011;12:E16.
ACCEPTED MANUSCRIPT 9
Figure legend:
RI PT
Figure 1: A) CT Scan shows thrombi-embolic occlusion of the main segmental pulmonary arteries. Common pulmonary trunk, main right and left pulmonary artery are thrombus free. B) Massive right heart
SC
dilatation is also visible in CT scan.
Figure 2: A) Trans-esophageal echocardiography before surgery shows massive right ventricular dilation
immediately after pulmonary embolectomy.
M AN U
and paradox movement of the septum. B) Rapid normalization of the right ventricular dimensions
AC C
EP
TE D
Figure 3: Blood clots after retraction from segmental and sub-segmental pulmonary arteries.
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
AC C
EP
TE D
M AN U
SC
RI PT
ACCEPTED MANUSCRIPT
S0890-5096(15)00495-1
DOI:
10.1016/j.avsg.2015.04.066
Reference:
AVSG 2413
To appear in:
Annals of Vascular Surgery
Received Date: 12 January 2015 Revised Date:
19 February 2015
Accepted Date: 1 April 2015
Please cite this article as: Colombier S, Niclauss L, Successful surgical pulmonary embolectomy for massive perinatal embolism after emergency cesarean section, Annals of Vascular Surgery (2015), doi: 10.1016/j.avsg.2015.04.066. This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT 1
Successful surgical pulmonary embolectomy for massive perinatal embolism after emergency cesarean
RI PT
section
Sébastien Colombier MD*
SC
Lars Niclauss MD*
M AN U
*Department of Cardiovascular Surgery, University Hospital of Lausanne (CHUV), Switzerland
Corresponding author: Lars Niclauss
TE D
Department of Cardio-vascular Surgery University Hospital of Lausanne
EP
46, rue du Bugnon
AC C
CH-1011 Lausanne, Switzerland
Tel: +41 (0)79 5561690 / Fax: +41 (0)21 3142278 E-mail address: [email protected] Funding: None
ACCEPTED MANUSCRIPT 2
Abstract:
RI PT
Pregnant women are exposed to an increased risk for developing pulmonary embolism (PE), a main cause for maternal mortality. Surgical pulmonary embolectomy is one important therapeutic and potential lifesaving armamentarium, considering pregnancy as a relative contraindication for thrombolysis. We present a case of a 36 year old woman with massive bilateral PE after emergent caesarean delivery, requiring
SC
reanimation by external heart massage. The onset of massive intra-uterine bleeding contraindicated thrombolysis and emergency surgical pulmonary embolectomy, followed by a hysterectomy, were
M AN U
preformed successfully. Acute surgical pulmonary embolectomy may be an option in critically diseased high risk patients, requiring a multi team approach, and should be part of the therapeutic armamentarium
AC C
EP
TE D
of the attending cardiac surgeon.
ACCEPTED MANUSCRIPT 3
Background: Pulmonary embolism (PE) in pregnant women is rare; however it is a severe disease and one major cause for maternal death in the developed world (1,2). Venous thrombo-embolism describes the frequent
RI PT
association of the (often silent) deep-vein thrombosis and PE. The incidence of venous thromboembolism is significantly higher during pregnancy and emergency caesarean delivery is one major risk factor in the early postpartum period (1,3,4). A reduced venous flow in the legs has been documented
SC
during the last trimester of gestation and lasts probably until 6 weeks after deliver (1). The clinical classification of the severity of acute PE distinguishes the massive, high-risk PE (shock or persistent
M AN U
arterial hypotension) from the sub-massive, not high-risk PE (without these symptoms), a differentiation with major impact on estimated in hospital mortality rate and on recommended medical care (5). In the former, urgent thrombolysis and (if contraindicated) surgical pulmonary embolectomy, will be potential live saving treatment strategies in patients with severe hemodynamic compromise. PE during pregnancy or after caesarean delivery may contraindicate thrombolysis (5). Several case reports suggest that prompt
TE D
diagnosis and a multidisciplinary approach, including surgical pulmonary embolectomy, may permit survival of these high risk patients (6,7). We present a case of successful surgical embolectomy for
Case presentation:
EP
massive pulmonary emboli during the immediate postnatal period after emergency caesarean section.
AC C
A 36 year old pregnant and healthy woman (BMI of 24 kg/m2, no history of thrombo-embolism) was admitted to the obstetrics department in her 36 week of gestation for pathologic cardiotocography after spontaneous membrane rupture. Emergency caesarean delivery was realized under local (epidural) anesthesia without intra-operative complication and a healthy baby was born. Half an hour after admission to the anesthetic recovery room, the patient became hemodynamically instable, presenting severe bradycardia and hypotension, followed by cardiac arrest requiring immediate cardio-respiratory resuscitation during five minutes. External cardiac massage, ventilation after emergency intubation and
ACCEPTED MANUSCRIPT 4
cardiac ionotropic drug support allowed a transitory stabilization. First arterial blood gas analysis after reanimation showed a global respiratory insufficiency and acidosis (pH 7.03, lactate 6.9 mmol/l, PO2 40 mmHg, PCO2 63 mmHg, SO2 85%). Echocardiography revealed a severe right heart dysfunction and
RI PT
massive dilatation, with an akinetic right ventricular (RV) free wall and a normal contracting RV apex (positive McConnel sign) and acute PE was the suspected main diagnosis (Fig.1) (8). Hemodynamic instability required increasing ionotropic drug support. The patient presented an active vaginal bleeding
SC
after cardiac reanimation and direct ultrasound examination confirmed intra-uterine hemorrhage. CT scan of the lungs confirmed the diagnosis of PE and showed an occlusion of the segmental and sub-segmental
M AN U
pulmonary arteries; however the main arteries were free, probably due to cardiac massage and consecutively thrombi pushing and fragmentation (Fig.2). Intra-uterine tamponade using a Bakri® postpartum balloon was realized for temporary hemostasis and the patient was transferred to the OR for emergency surgical pulmonary embolectomy. After median sternotomy, aortic and bi-caval cannulation, pulmonary embolectomy was performed through a longitudinal pulmonary arteriotomy under cardiac
TE D
arrest. Gentle squeezing of both lungs (after both pleural spaces had been widely opened) enabled a backwards pushing of large thrombi in both main pulmonary arteries and subsequent removal (Fig.3). The patient got off bypass with persistent right heart dysfunction but with normal blood oxygenation. After
EP
sternal closure, hysterectomy was performed due to ongoing bleeding from the uterus. A vena cava filter was inserted via the common femoral vein at postoperative day one. Laparotomy with initial abdominal
AC C
packing was closed two days later and continuous postoperative recovery in the ICU unit allowed extubation at postoperative day four. The patient left hospital ten days later with good general postoperative recovery, a moderate right heart dysfunction (according to the guidelines from the American Society of Echocardiography) and a persistent pulmonary hypertension, with a pulmonary arterial pressure (PAP) of 30 mmHg, at echocardiography (9). A systematic oral anticoagulation therapy by warfarin has been started during hospitalization and maintained for at least three months postoperatively.
ACCEPTED MANUSCRIPT 5
Follow up at three months showed a persistent right ventricular dilatation and moderate dysfunction (9). Patient complained a persistent slight dyspnea at physical effort (NYHA II). Cardiac catheterization
RI PT
showed a normal systolic /diastolic PAP of 18/7 mmHg (corresponding to a mean PAP of 11 mmHg).
Discussion:
SC
Pregnant women are exposed to an increased risk for developing PE, a main cause for maternal mortality (1,3). To ensure survival in massive PE, rapid diagnosis and multidisciplinary approaches, including
M AN U
surgical strategies, should be mandatory. Surgical pulmonary embolectomy is one important therapeutic and potential life-saving armamentarium to treat these patients, considering pregnancy as a relative contraindication for thrombolysis (5). Several case reports have documented successful surgical interventions in these circumstances (6,10). We present a case of a perinatal massive PE immediately after emergent caesarean section. Main contraindication for thrombolytic therapy, in this
TE D
hemodynamically instable patient presenting severe right heart dysfunction, was given due to severe intrauterine post caesarean bleeding. Causal factors for a probably ongoing, and finally, after cardiac reanimation, massive bleeding, were, as well as a non compaction of the dilated and (after a caesarean)
EP
surgically injured uterus, an important venous hypertension due to congestive right heart failure. Severe cardiogenic shock and the onset of beginning concomitant disseminated intravascular coagulation in a
AC C
comatose and highly instable patient, were further contributing factors maintaining the bleeding. To our knowledge, this is the second description of a successfully treated patient having undergone emergency surgical pulmonary embolectomy in these clinical circumstances (11). Although caesarean section is a major risk factor for developing PE, diagnosis and treatment algorithms remain challenging. Echocardiography is a rapidly available diagnostic tool in order to identify right heart dysfunction and increased pulmonary pressure as indirect signs (8). Direct visualization of thrombi in the pulmonary artery tree may also be possible (11). In the present case, successful cardiac resuscitation for transitory
ACCEPTED MANUSCRIPT 6
stabilization of the patient required external heart massage. Therefore blood clots initially located in the main central pulmonary arteries had probably been pushed more distally (Fig 2). Ct scan in cases of nonvisualization of pulmonary emboli at echocardiography seems to be crucial for the correct diagnosis and
RI PT
to evaluate the feasibility of the surgical approach. If thrombi occlude the segmental branches of the lungs susceptible for acute right heart failure, surgical removal should be envisaged.
SC
Conclusion:
M AN U
Guidelines indicate thrombolytic therapy as the treatment of choice for PE in high risk patients (cardiogenic shock due to massive PE). If contraindications do exist, acute pulmonary embolectomy is indicated as a reserve strategy (5). The present case shows that surgery has its role in complicated emergency situations requiring a multi team approach. Acute surgical pulmonary embolectomy may be an option in critically diseased high risk patients and should be part of the therapeutic armamentarium of the
AC C
EP
TE D
attending cardiac surgeon.
ACCEPTED MANUSCRIPT 7
RI PT
References:
Marik PE, Plante LA. Venous thromboembolic disease and pregnancy. N Engl J Med. 2008;359:2025-33. Berg CJ, Chang J, Callaghan WM, Whitehead SJ. Pregnancy-related mortality in the United States, 1991-
SC
1997. Obstet Gynecol. 2003;101:289-96.
M AN U
Simpson EL, Lawrenson RA, Nightingale AL, Farmer RD. Venous thromboembolism in pregnancy and the puerperium: incidence and additional risk factors from a London perinatal database. BJOG. 2001;108:56-60.
Jacobsen AF, Skjeldestad FE, Sandset PM. Ante- and postnatal risk factors of venous thrombosis: a
TE D
hospital-based case-control study. J Thromb Haemost. 2008;6:905-12.
Konstantinides SV, Torbicki A, Agnelli G, Danchin N, Fitzmaurice D, Galiè N et al. 2014 ESC Guidelines on the diagnosis and management of acute pulmonary embolism: The Task Force for the Diagnosis and Management of Acute Pulmonary Embolism of the European Society of Cardiology (ESC)
EP
Endorsed by the European Respiratory Society (ERS). Eur Heart J. 2014;35:3033-73.
AC C
Saeed G, Möller M, Neuzner J, Gradaus R, Stein W, Langebrake U et al. Emergent surgical pulmonary embolectomy in a pregnant woman: case report and literature review. Tex Heart Inst J. 2014;41:188-94. Taniguchi S, Fukuda I, Minakawa M, Watanabe K, Daitoku K, Suzuki Y. Emergency pulmonary embolectomy during the second trimester of pregnancy: report of a case. Surg Today.2008;38:59-61. Haller EP, Nestler DM, Campbell RL, Bellamkonda VR. Point-of-care ultrasound findings of acute pulmonary embolism: McConnell sign in emergency medicine. J Emerg Med. 2014;47:e19-21.
ACCEPTED MANUSCRIPT 8
Rudski LG, Lai WW, Afilalo J, Hua L, Handschumacher MD, Chandrasekaran K et al. Guidelines for the echocardiographic assessment of the right heart in adults: a report from the American Society of Echocardiography endorsed by the European Association of Echocardiography, a registered branch of the
RI PT
European Society of Cardiology, and the Canadian Society of Echocardiography. J Am Soc Echocardiogr. 2010 ;23:685-713.
Waldman M, Sheiner E, Sergienko R, Shoham-Vardi I. Can we identify risk factors during pregnancy for
SC
thrombo-embolic events during the puerperium and later in life? Matern Fetal Neonatal Med. 2014;31:15.
M AN U
Wei J, Yang HS, Tsai SK, Hsiung MC, Chang CY, Ou CH et al. Emergent bedside real-time threedimensional transesophageal echocardiography in a patient with cardiac arrest following a caesarean
AC C
EP
TE D
section. Eur J Echocardiogr. 2011;12:E16.
ACCEPTED MANUSCRIPT 9
Figure legend:
RI PT
Figure 1: A) CT Scan shows thrombi-embolic occlusion of the main segmental pulmonary arteries. Common pulmonary trunk, main right and left pulmonary artery are thrombus free. B) Massive right heart
SC
dilatation is also visible in CT scan.
Figure 2: A) Trans-esophageal echocardiography before surgery shows massive right ventricular dilation
immediately after pulmonary embolectomy.
M AN U
and paradox movement of the septum. B) Rapid normalization of the right ventricular dimensions
AC C
EP
TE D
Figure 3: Blood clots after retraction from segmental and sub-segmental pulmonary arteries.
AC C
EP
TE D
M AN U
SC
RI PT
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AC C
EP
TE D
M AN U
SC
RI PT
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EP
TE D
M AN U
SC
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