I thank Dr. Nowak et al.  for their interest in my case report1and appreciate the opportunity to reply. There is currently no recommendation for the treatment of acute pulmonary embolism (APE) complicated by embolized type A thrombus in the right cardiac cavities.2However, Rose et al.  3suggested that it was reasonable to advocate thrombolysis as frontline treatment after careful screening for contraindications and to reserve surgical thrombectomy for patients with contraindications to thrombolysis or in cases of failure of thrombolysis. For me, the interest in this case report was double. My first interest was to underline the utility of transthoracic echocardiography and transesophageal echocardiography not only for hemodynamic monitoring and management of acute heart failure, but also for systematic research of embolized thrombi in cardiac cavities. Their presence, 3 to 26% in the literature, directly influences the prognosis, with a mortality significantly higher (26–50%) with regard to 8 to 10% for “isolated” pulmonary embolisms.3,4Therefore, it seems essential to search and locate these thrombi precisely, not in the intraoperative period, but immediately after the diagnosis of massive APE, because this minimally invasive and fast examination will directly affect therapeutic decisions.5With regard to the diagnosis of inferior vena cava thrombosis, I think that when APE is diagnosed on helicoidal computed tomography pulmonary angiography, the addition of venous phase imaging of the abdomen and pelvis is useful and more powerful than transesophageal echocardiography because it allows complete exploration of the femoro-ilio-caval venous network.6 

My second interest was to report the experience of our team in the management of a particular APE complicated by the presence of a type A thrombus, floating in both right and left cardiac cavities through the oval foramen. We chose the surgical thrombectomy as treatment of choice because of the high risk of systemic embolism, in particular cerebral, making thrombolysis dangerous. In our practice, we choose surgical thrombectomy first in these clinical situations or in the presence of contraindications to thrombolysis and second if thrombolysis is ineffective. We do not consider thrombolysis as an absolute weapon but as one of the therapeutic alternatives available in the management of serious APE as well as surgical thrombectomy. Caval or pelvic venous thrombus does not seem to me to constitute a real contraindication to thrombolysis because, even though the fragmentation of the thrombus with pulmonary embolization is often feared by the physicians, it could never be shown clinically.7,8Thrombolytic therapy can be given quickly; is available at all centers; and results in the simultaneous thrombolysis of venous, cardiac, and pulmonary clots. In addition, I think that surgical thrombectomy should not be reserved for desperate cases of refractory cardiogenic shock or cardiac arrest, where mortality is close to 100%. A well-designed, prospective, randomized, multicenter trial is needed to determine which treatment has the best cost-effectiveness/safety ratio.

Centre Hospitalier Jolimont-Lobbes, Haine-Saint-Paul, Belgium. benoit.espeel@skynet.be

Espeel B, Crispin V, Fraselle B, Payen B, Versailles H: Floating thrombus entrapped in a patent foramen ovale complicating acute pulmonary embolism. Anesthesiology 2005; 103:895–7
Chartier L, Bera J, Delomez M, Asseman P, Beregi JP, Bauchart JJ, Warembourg H, Thery C: Free-floating thrombi in the right heart: Diagnosis, management, and prognostic indexes in 38 consecutive patients. Circulation 1999; 99:2779–83
Rose PS, Punjabi NM, Pearse DB: Treatment of right heart thromboemboli. Chest 2002; 121:806–14
Shah CP, Thakur RK, Ip JH, Xie B, Guiraudon GM: Management of mobile right atrial thrombi: A therapeutic dilemma. J Card Surg 1996; 11:428–31
Krivec B, Voga G, Zuran I, Skale R, Pareznik R, Podbregar M, Noc M: Diagnosis and treatment of shock due to massive pulmonary embolism: Approach with transesophageal echocardiography and intrapulmonary thrombolysis. Chest 1997; 112:1310–6
Loud PA, Katz DS, Bruce DA, Klippenstein DL, Grossman ZD: Deep venous thrombosis with suspected pulmonary embolism: Detection with combined CT venography and pulmonary angiography. Radiology 2001; 219:498–502
Greco F, Bisignani G, Serafini O, Guzzo D, Stingone A, Plastina F: Successful treatment of right heart thromboemboli with IV recombinant tissue-type plasminogen activator during continuous echocardiographic monitoring: A case series report. Chest 1999; 116:78–82
Girard P: Inferior vena cava interruption: How and when? Rev Mal Respir 1999; 16:975–84