Utility of Two-dimensional and Three-dimensional Transesophageal Echocardiography in Surgical Management of Acute-on-chronic Pulmonary Embolism with Serpiginous Right Atrial Thrombus: Case Report with Review of Literature

We report a case of deep vein thrombosis with acute-on-chronic pulmonary embolism, complicated by a large mobile right atrial (RA) thrombus. The patient underwent successful RA clot excision and pulmonary thromboendarterectomy on cardiopulmonary bypass (CPB) and deep hypothermic circulatory arrest. Perioperative two-dimensional and three-dimensional transesophageal echocardiography (TEE) helped localize the serpiginous RA thrombus and a right pulmonary embolus and demonstrated a thrombus-free, dilated inferior vena cava with severe right ventricular (RV) dysfunction. After successful RA thrombus excision, right pulmonary embolectomy, and extensive bilateral pulmonary thromboendarterectomy, the patient was weaned off CPB in sinus rhythm with dobutamine and epinephrine as inotropic supports with lung protective ventilation. Postoperative TEE demonstrated no residual thrombus in RA or RPA, reduced tricuspid regurgitation and pulmonary hypertension by Grade II, and improved RV function. The case highlights the importance of TEE in guiding surgical intervention and in real-time perioperative cardiac monitoring during life-threatening thromboembolic events. The literature review synthesizes the key clinical considerations and role of TEE in perioperative surgical and medical management of such case scenarios.