F orty-three percent of cases of pulmonary embolism occur after abdominal surgery, of which 0.44% result in mortality (1). We report a case of sudden cardiac arrest 10 days after radical hysterectomy as a result of a total tricuspid valve obstruction and massive pulmonary embolism, which were immediately diagnosed with the use of bedside transesophageal echocardiography (TEE). The patient survived after effective resuscitation, extracorporeal membrane oxygenation (ECMO), and emergent pulmonary

more »

... hromboembolectomy. The usefulness of bedside TEE is demonstrated. Case Report A 58-yr-old, 60-kg woman presented with squamous cell carcinoma of the uterine cervix. Radical hysterectomy was successfully performed with general anesthesia without immediate postoperative complications. On the tenth postoperative day, the patient developed sudden cardiac arrest. Cardiopulmonary resuscitation (CPR) was initiated with artificial ventilation via endotracheal intubation and external cardiac massage. After the IV administration of epinephrine (5 mg total), a systolic blood pressure of 80 mm Hg and a pulse rate of 140 bpm were obtained. Within 5 min, however, blood pressure decreased rapidly. Cardiac arrest ensued again and did not respond to further CPR. Emergent TEE was performed at the bedside during the resuscitation, which revealed marked dilation of the right atrium, a small right ventricle (RV), and nearly empty chambers of the left heart. Massive thromboemboli in the right atrium were found trapped at the tricuspid valve, resulting in total obstruction (Fig. 1) . In an attempt to resolve the RV inflow obstruction, a right internal jugular venous catheter was inserted, and a large amount of small emboli was aspirated. However, a large mass was shown by TEE to remain trapped in the tricuspid valve. In an attempt to dislodge the embolus, we shook the patient vigorously. Figures 2 and 3 show that the embolus subsequently moved to the pulmonary artery (PA), passing through the RV. Systolic blood pressure returned to 60 mm Hg with a heart rate of 150 bpm, and the patient responded to verbal command. She was then transferred to the intensive care unit, where after IV infusion of heparin 6000 units, ECMO was immediately established via femoral arterial and venous cannulations. Once stabilized with ECMO, the patient was brought to the operating room for emergent pulmonary artery thromboembolectomy. Anesthesia was induced with IV ketamine 2 mg/kg and maintained with fentanyl/O 2 and pancuronium. Thromboemboli were removed from the main, right, and left PAs. Pathological examination showed three tissue fragments of brown color, measuring 30 cm in total length and 1 cm in diameter. Repeated intraoperative and postoperative TEE revealed no residual emboli in the right heart or the PA after the embolectomy. Postoperative vital signs were stable, and the patient recovered without further incident, but hemodialysis was required because of acute renal failure. The ECMO was discontinued on the second postoperative day. Duplex Doppler examination of the lower limbs showed increased deep venous resistance, and the patient continued to receive 2000 units of IV heparin daily for 3 wk, followed by oral warfarin. Twenty days later, her renal function recovered, and hemodialysis was discontinued. Subsequently, she underwent bladder rehabilitation and psychiatric treatment for acute depression and was discharged without residual deficits after 70 days of hospitalization. Discussion Most pulmonary emboli are microscopic, and with early diagnosis and prophylactic therapy, catastrophic pulmonary embolism is rare. Nevertheless, pulmonary embolism still accounts for 5% of all hospital mortality, or approximately 60,000 deaths each year, in the United States (2-4). TEE is a useful technique in the diagnosis of pulmonary emboli (5-9). In our case, sudden cardiac arrest developed as a result of mechanical obstruction of the tricuspid valve by massive thromboemboli, as