Current management strategies of acute major pulmonary embolism are largely dependent on the degree of hemodynamic instability at presentation. In the presence of severe hemodynamic compromise, physicians often rely on the findings of bedside echocardiography and proceed to thrombolytic treatment without seeking further diagnostic certainty in nuclear imaging or angiographic studies.

When given in conjunction with heparin, alteplase can improve the clinical course of stable patients who have acute submassive pulmonary embolism and can prevent clinical deterioration requiring the escalation of treatment during the hospital stay.

Right ventricular involvement during acute inferior myocardial infarction can be accurately diagnosed by the presence of ST-segment elevation in lead V4R, a finding that is a strong, independent predictor of major complications and in-hospital mortality. Electrocardiographic assessment of right ventricular infarction should be routinely performed in all patients with acute inferior myocardial infarctions.

BACKGROUND During the past few years, transesophageal echocardiography (TEE) has been increasingly used in clinical cardiology; data concerning the practicability and safety of the technique, however, are rare. METHODS AND RESULTS This report analyzes the experience of 15 European centers performing TEE studies for at least 1 year. At the time of this survey, 10,419 TEE examinations had been attempted or performed in these institutions. These TEE examinations were carried out by 54 physicians, 53.7% of whom had been trained in endoscopic techniques. Within the same time period, 160,431 precordial echocardiographic examinations were performed in the 15 institutions; the ratio between TEE and transthoracic studies averaged 9.03 +/- 6.4% (range of the 15 centers, 1.4-23.6%). Of the 10,419 patients, 9,240 (88.7%) were conscious inpatients or outpatients at the time of the TEE examination; the vast majority of the conscious patients did not receive intravenous sedation before TEE. In 201 cases (1.9%), insertion of the TEE probe was unsuccessfully attempted because of a lack of patient cooperation and/or operator experience (98.5%) or because of anatomical reasons (1.5%). In 90 of 10,218 TEE studies (0.88%) with successful probe insertion, the examination had to be interrupted because of the patient's intolerance of the echoscope (65 cases); because of pulmonary (eight cases), cardiac (eight cases), or bleeding complications (two cases); or for other reasons (seven cases). One of the bleeding complications resulted from a malignant lung tumor with esophageal infiltration and was fatal (mortality rate, 0.0098%). CONCLUSIONS This multicenter survey documents that TEE studies are associated with an acceptable low risk when used by experienced operators under proper safety conditions.

The results of our study suggest that thrombolysis may favorably affect the clinical outcome of hemodynamically stable patients with major pulmonary embolism.