Systematic study of occult pulmonary thromboembolism in patients with deep venous thrombosis

PURPOSE: This study was carried out to evaluate the prevalence and extension of pulmonary thromboembolism (PTE) in symptom-free patients with symptomatic deep venous thrombosis (DVT) of lower limbs and to evaluate their possible implication in the adequate treatment of thromboembolic disease. MATERIALS AND METHODS: We prospectively studied, using noninvasive examination (pulmonary spiral computed tomography [CT] angiography), 159 consecutive patients with acute DVT confirmed by duplex scanning without symptoms of PTE. CT was repeated at 30 days to study evolution of these clinically occult PTE. RESULTS: We observed silent PTE in 65 patients (41%) in all levels of lower limb venous thrombosis. Prevalence of PTE showed significant association with male sex (P =.001) and previously diagnosed heart disease (P =.023). There was no significant association between the level of DVT and the presence of PTE nor the DVT side and thromboembolic pulmonary localization. Of the 65 patients with positive CT exploration results for PTE, 52 had characteristics of acute PTE, 10 had chronic PTE, and 3 patients had both. Chronic PTE was found more frequently in patients with previous episodes of DVT (P =.024). A total of 165 pulmonary artery-affected segments were found at several locations: 5 main, 35 lobar, 58 interlobar, and 67 segmental. Multiple segments were affected in 59% of patients. Repeat CT examinations were performed at 30 days in 53 of 65 patients with positive CT scanning results. In 48 cases (90.6%) PTE had completely disappeared. CONCLUSIONS: Silent PTE occurred frequently in association with clots of lower limbs. The CT scan had a good availability and cost-effectiveness to detect clinically underestimated PTE. The incorporation of this exploration in the systematic diagnostic strategy of most patients with DVT to establish the extension of thromboembolic disease at diagnosis may be useful in the evaluation of added pulmonary artery symptoms and treatment strategies.     

肺动脉栓塞外科治疗的围术期及中长期效果分析

目的探讨提高外科治疗肺动脉栓塞（pulmonary thromboembolism，PTE）的围术期和中长期疗效的方法。方法回顾性分析1994年10月至2007年10月北京安贞医院手术治疗57例PTE的临床资料，其中47例慢性PTE患者在深低温停循环（22例）或不停循环下（心脏停搏21例，心脏不停跳4例）行肺动脉血栓内膜剥脱术；10例急性PTE患者在中低温体外循环下行肺动脉切开取栓术。结果围术期慢性PTE患者死亡6例（12．8％），急性PTE患者死亡4例（40．0％，P=0．030）。术后发生残余肺动脉高压15例，出现重度肺组织再灌注损伤25例。41例慢性PTE患者术后72h肺动脉收缩压和肺血管阻力较术前降低（52．9±26．1mmHgvs．91．2±37．4mmHg；410．3±345．6dyn·s／cm^5vs．921．3±497．8dyn·s／cm^5）；动脉血氧饱和度和动脉血氧分压较术前增高（94．8％±2．7％vs．86．7％±4．3％；84．4±5．4mmHgvs．51．8±6．4mmHg，P〈0．05）。随访47例，随访时间44．6±39．3个月，累积随访时间为160．1人年。晚期死亡5例，其中慢性PTE4例，急性PTE1例。慢性PTE患者术后5年Kaplan—Meier生存曲线生存率为89．43％±5．80％，而急性PTE患者术后1～5年为83．33％±15．21％（Log rank=1．57，P=0．2103）。全组抗凝相关出血线性发生率为1．25％病人年，再发PTE线性发生率为0．62％病人年。中长期生存的42例患者中，心功能分级（NYHA）Ⅰ级29例、Ⅱ级10例、Ⅲ级3例。logistic回归分析发现，急性PTE（OR=3．28）、外周型PTE（OR=2．45）、未采用深低温停循环（OR=2．86）为早期死亡的危险因素；外周型PTE（OR=2．69）、术前下肢水肿（OR=2．79）为晚期死亡的危险因素。结论急性PTE患者围术期死亡率显著高于慢性PTE，两者术后均有较好的中长期生存率，差异无统计学意义。口服华法林抗凝相关的再发PTE、出血并发症线性发生率均较低，在可接受?     

Pulmonary embolectomy for acute massive pulmonary thromboembolism after failure of thrombolytic therapy

Acute massive pulmonary thromboembolism (PTE) is associated with an exceptionally high mortality rate and results in death if not diagnosed early and treated properly. We observed 3 cases of acute massive PTE. One of the patients had undergone a surgery for femoral neck fracture. Ten days postoperatively, she developed severe dyspnea with hypoxia, and computed tomography (CT) pulmonary angiography confirmed the PTE diagnosis. She then had cardiac arrest when catheter examination. Although emergency surgical thrombectomy was successful with good postoperative hemodynamic stability and oxygenation, the patient did not recover from the unconsciousness caused by preoperative ischemic brain damage. Subsequently, she died 6 months after surgery. Of the 3 patients, 2 suffered from right ventricular dysfunction without hemodynamic instability. They underwent open thrombectomy after the failure of conservative treatment with a systemic injection of urokinase. Both patients demonstrated a good clinical course and were discharged from hospital in a good general condition 22 and 28 days postoperatively. Herein, we review the current literature on PTE treatment. We concluded that an aggressive surgical intervention might be preferred to thrombolytic therapy for PTE patients with massive thrombosis and progressive right ventricular dysfunction.     

Veno-venous extracorporeal membrane oxygenation as a bridge to and support for pulmonary thromboendarterectomy in misdiagnosed chronic thromboembolic pulmonary hypertension

Diagnostic delay in patients suffering massive pulmonary embolism (PE) on chronic thromboembolic pulmonary hypertension (CTEPH) has inevitably fatal consequences. Indications to pulmonary thromboendarterectomy (PTE) and extracorporeal membrane oxygenation (ECMO) are limited by severe comorbid conditions, some of which, as neurologic disease, absolutely contraindicate these procedures. We reported the clinical course of a severely diseased patient with a history of meningitis, psychosis and epilepsy, experiencing acute massive pulmonary embolism complicated by acute respiratory failure, successfully treated by ECMO and PTE. A 51-year-old woman with massive PE complicating a misdiagnosed CTEPH needed mechanical ventilation because of acute respiratory insufficiency. Thoracic computed tomography (CT) scan demonstrated PE, and brain CT showed multiple cerebral and cerebellar ischemic lesions. Veno-venous ECMO assistance was instituted despite CT imaging. She recovered from acute respiratory insufficiency by means of veno-venous ECMO. Weaning from ECMO was however impossible until surgical exploration demonstrated an underlying chronic CTEPH, which was successfully addressed by PTE, switching the ECMO system to a standard cardiopulmonary bypass. Postoperative course was uneventful and the patient was discharged home in healthy condition. Despite the fact that the cost-effective ratio should always be considered in advanced life support, expanding the commonly accepted selection criteria for expensive procedures might be advisable in selected acute life-threatening cases, in view of the possibility to unexpectedly save lives.     

Survival after intraoperative pulmonary embolism of a patient with left adrenal tumor

We report a case of severe shock associated with intraoperative pulmonary embolism (PE). A 15-year-old girl was scheduled to undergo left adrenalectomy and removal of vena cava tumor thrombi. She had suffered from preoperative PE and a temporary IVC filter had been inserted. After left adrenalectomy and removal of vena cava tumor thrombi, IVC was declamped. Forty-five minutes after IVC declamping, circulatory collapse developed with severe hypoxia. Transesophageal echocardiography (TEE) revealed right ventricular dysfunction. We diagnosed PE and immediately started cardiopulmonary resuscitation. Ten minutes later, a stable cardio-respiratory condition was reestablished. TEE findings showed the restoration of right ventricular function. She recovered without any neurological complications. TEE may be useful for diagnosis of acute PE by secondary signs of pulmonary artery obstruction. When intraoperative PE is suspected, TEE should be used for early diagnoss of PE and monitoring cardiac function. This case also suggests that cardiopulmonary resuscitation maneuvers may ameliorate PE itself.     

骨科围手术期急性致死性肺栓塞的诊断和治疗

[目的]提高对骨科围手术期急性致死性肺血栓栓塞症的认识,选择正确的早期诊断及治疗方法。[方法]回顾性分析2002年2月~2005年7月12例于骨科围手术期确诊为急性致死性肺血栓栓塞症的患者的临床表现、影像学及实验室检查结果、治疗方法和预后。[结果]本组12例中,9例进行溶栓及抗凝治疗,其中7例症状明显改善,痊愈出院,2例死亡;3例心跳骤停患者抢救无效死亡。[结论]急性致死性肺血栓栓塞症是骨科围手术期的急危重症,必须提高认识、早期诊断、早期治疗,才能改善预后、减少病死率。     

Catheter-induced thrombus in the superior vena cava diagnosed by transesophageal echocardiography

Background: To present the role of transesophageal echocardiography (TEE) in the diagnosis and management of catheter-related superior vena cava thrombosis.
Case history: A 42-year-old woman with severe Crohn's disease presented with septic shock and pulmonary embolism three weeks after emergency laparotomy and ileocolic resection for small-bowel perforation with peritonitis. Cardiopulmonary evaluation with ECG, pulmonary artery catheter and TEE demonstrated no evidence of acute myocardial ischemia or ventricular dysfunction; hemodynamic indices were consistent with severe sepsis. TEE revealed a large sheathing thrombus surrounding a central venous catheter used for parenteral nutrition. A spiral CT scan of the chest confirmed multiple peripheral pulmonary emboli. Treatment consisted of systemic anticoagulation and antibiotics. To avoid further pulmonary embolism, the central venous catheter was not removed until six days later under TEE monitoring, which revealed that the thrombus was firmly adherent to the superior vena cava. The patient made an uneventful recovery and was discharged from hospital on long-term anticoagulant therapy.
Conclusion: In a case of catheter-induced superior vena cava thrombosis with septicemia and pulmonary embolism, bedside TEE was very helpful to make the correct diagnosis early, assess thrombus size during anticoagulation, and monitor cardiac performance and thrombus disposition during central venous catheter removal.     

Our experience of surgical treatment for chronic pulmonary thromboembolism.

Chronic pulmonary thromboembolism is one of the causes of pulmonary hypertension and carries a poor prognosis. Medical therapy is generally unsatisfactory, and surgery provides the only possibility of a cure. Though over 1400 cases have undergone pulmonary thromboendarterectomy (PTE) worldwide, the surgical procedure is performed with success only at a few institutions. It is important to select suitable patients, to perform PTE (not an embolectomy) and to manage successfully postoperatively. We report our experiences of surgical treatment for chronic pulmonary thromboembolism. Between June 1986 and March 2001, 50 patients (15 men, 35 women) underwent PTE at our hospital. The mean age was 51.3 years (range 22-73). We have adopted two surgical approaches to PTE. The number of operation deaths was 9 (18.0%). Forty-one patients survived, and the declines in their mean pulmonary arterial pressures (m-PAP) and pulmonary vascular resistance (PVR), and the inceraeses in cardiac indices (C.I.), were significant postoperatively. Their PaO2 improved significantly after 6 months. The symptoms were markedly reduced, and survival after PTE was 86-88% at 10 years. The only therapeutic alternative to PTE is lung transplantation. The great advantage of PTE includes an excellent long-term results without the risks associated with chronic immunosuppression and potential for chronic allograft rejection. We conclude that PTE can improve the prognosis of selected patients with chronic pulmonary thromboembolism, and morphological classification by CT scan could be useful for predictions about the surgical accessibility.     

Pulmonary thromboembolism in patients after surgery for pulmonary malignant tumor

From January 1994 to December 2004, 6 of 1,034 patients (0.58%) with pulmonary malignant tumor developed pulmonary thromboembolism (PTE) after surgery in our department. Five of 6 patients had primary lung cancer, and 1 had metastatic lung tumor. The surgeries for the 6 patients contain 1 exploration thoracotomy, 1 wedge resection, 3 lobectomies, and 1 pneumonectomy. The length of time between operation and making diagnosis of PTE was 2-7 days. All 6 patients initially showed symptoms of desaturation and tachycardia. Chest computed tomography (CT) was the most useful diagnostic method. In all cases, we started intravenous administration of unfractionated heparin sodium immediately after making diagnosis. In 2 cases, we needed to add thrombolysis by urokinase because of their serious condition. One patient in whom the establishment of diagnosis took longer time died on the postoperative day 9, in spite of the removal of the thrombus by percutaneous approach. The other 5 patients made a recovery and observed no signs of recurrence of PTE after 6-month anticoagulant therapy by warfarin potassium. PTE can be treated only with anticoagulant therapy if we confirm the diagnosis and start the treatment immediately after the first episode.     

手术相关肺栓塞45例临床分析

目的 回顾分析手术后患者肺栓塞的发病情况,以引起外科医师对该病预防和诊治的重视.方法 回顾性分析2004年6月至2009年2月共45例手术后肺栓塞患者的临床资料.从患者的手术种类、手术时间、麻醉方式、发生肺栓塞的危险因素、临床表现、辅助检查、诊断、治疗及转归等方面进行综合分析.结果 45 例患者中,平均年龄(60±16)岁,其中抗凝治疗35例,溶栓治疗6例,仅予急救治疗4例,37例(82.2%)肺栓塞发生于术后2周内,占同期住院肺栓塞患者的13.2%(45/341).肺栓塞最常见于普通外科(35.6%)、妇产科(13.3%)、骨科(13.3%)、胸外科(11.1%)等手术,尤其是与恶性肿瘤相关手术术后(57.8%).平均手术时间(220±124)min,全身麻醉37例(82.2%).临床表现及辅助检查缺乏特异性;经抗凝等治疗好转36例,死亡9例,病死率20.0%(9/45).结论 手术是发生肺栓塞的重要危险因素,应该重视手术相关肺栓塞的预防和诊治.     

经导管抽吸血栓联合接触性溶栓治疗急性中-高危与高危肺血栓栓塞

目的 观察经导管抽吸血栓联合接触性溶栓（CDT）治疗急性中-高危与高危肺血栓栓塞（PTE）的效果。方法 对28例急性中-高危或高危PTE患者于置入下腔静脉滤器后行经导管抽吸血栓及CDT;观察治疗后临床症状有无改善,对比治疗前及治疗后72 h动脉血气分析、凝血功能、血常规、肺动脉压（PAP）及右心室直径/左心室直径（RV/LV）等,记录治疗相关并发症。随访观察治疗后1、3、6个月及1年PAP及肺动脉血栓清除效果。结果 治疗后26例症状明显改善,2例死于呼吸衰竭。4例穿刺点出血,均经保守治疗后好转。相比治疗前,治疗后72 h,26例存活者血pH、动脉氧分压、血纤维蛋白降解产物及D-二聚体水平均升高,而心率、N-末端B型利钠肽原、PAP及RV/LV均下降（P均<0.05）。治疗后1、3、6个月及1年PAP均较治疗前降低,肺血栓清除率均较治疗前升高（P均<0.05）;未见活动性出血及PTE复发。结论 经导管抽吸血栓联合CDT可安全、有效地治疗急性中-高危与高危PTE。     

Utility of intraoperative transesophageal echocardiography for diagnosis of pulmonary embolism

Pulmonary embolism (PE) is associated with significant perioperative morbidity and mortality. Transesophageal echocardiography (TEE) may permit direct visualization of PE or secondary signs of pulmonary artery (PA) obstruction. However, its utility in diagnosing PE in the intraoperative setting has yet to be defined. Therefore, we performed intraoperative TEE examinations in 46 patients immediately before pulmonary embolectomy. TEE examinations were reviewed for signs of thromboemboli within the right, left, and main PA, and secondary signs of acute PA obstruction (right ventricular dysfunction, moderate-to-severe tricuspid regurgitation, leftward bowing of the interatrial septum). The definitive location of thromboemboli was determined from the surgical record. Echocardiographic evidence for the presence of PE was correctly demonstrated in 46% of all patients (n = 21 of 46). However, the sensitivity for direct visualization of thromboemboli at any specific location was only 26%. TEE was least sensitive for thromboemboli in the left PA (17%). TEE evidence of right ventricular dysfunction was observed in 96%, tricuspid regurgitation in 50%, and leftward interatrial septal bowing in 98% of examinations. Therefore, the use of intraoperative TEE to diagnose acute PE via direct visualization is limited. Indirect TEE evidence of PA obstruction may be helpful in supporting a diagnosis of PE.     

Pulmonary calcification in long-term hemodialysis: a mimic of pulmonary thromboembolism

Metastatic pulmonary calcification is a frequent complication of chronic renal failure, especially in patients undergoing maintenance hemodialysis. We report a patient with chronic renal failure, who developed chest pain and hypoxia suggestive of pulmonary thromboembolism (PTE) and subsequently died. The ventilation/perfusion (V/Q) scan was also interpreted as consistent with PTE. At autopsy the areas of reduced perfusion on the scan corresponded to the areas of pulmonary calcification with no evidence of PTE. Physicians should be aware that this condition may mimic PTE, and that pulmonary angiography may be necessary to confirm the diagnosis prior to the initiation of anticoagulation.     

开胸术后并发急性肺动脉栓塞的诊断与治疗

目的 探讨开胸术后并发急性肺动脉血栓栓塞(PTE)的诊断与治疗方法。方法分析2001年1月～2002年6月间诊治的5例胸部肿瘤开胸术后并发PTE病例的临床资料。结果5例患者于术后72～168h出现突发憋气、胸痛、心悸等症状,查体为呼吸急促、血压下降、心动过速。经多普勒超声心动图、螺旋CT肺动脉造影检查明确FIE诊断。3例于确诊当日行肺动脉介入破碎、吸出血栓及溶栓治疗,1例行全身溶栓治疗。行溶栓治疗的4例痊愈,无胸腔出血、伤口渗血等并发症,无复发。1例未能行溶栓治疗即猝死。结论胸部肿瘤开胸术后患者是PTE的高发人群。PTE诊断以影像学检查为主。开胸术后PTE患者采用溶栓治疗应谨慎,并尽可能应用肺动脉介入治疗,经导管破碎、吸出血栓加局部溶栓。     

Current early results of pulmonary thromboendarterectomy for chronic pulmonary embolism

Some patients with chronic pulmonary embolism causing severely symptomatic pulmonary hypertension have been managed by heart-lung transplantation with an associated hospital mortality of 24%. To allow comparison with pulmonary thromboendarterectomy (PTE), we have reviewed the hospital morbidity and mortality in 149 consecutive patients. From 1 October 1984 to 18 September 1989, these patients underwent PTE utilizing a standardized procedure consisting of median sternotomy, cardiopulmonary bypass, deep hypothermia and circulatory arrest for bilateral PTE in 91% (136/149) of the procedures with 7.4% (11/149) and 1.3% (2/149) undergoing right or left PTE, respectively. Ventilator dependency (greater than or equal to 5 days on respirator) occurred in 28.3% (41/146). Hospital mortality (death within 30 days or in hospital) was 11.4% (17/149). The most common causes of death were respiratory and multiorgan failure, 10 (59% of deaths) and acute pulmonary hemorrhage, 3 (17% of deaths). We conclude that PTE with an operative mortality of half that of heart-lung transplantation (11.4% vs. 24%) should be the procedure of choice for significantly symptomatic chronic pulmonary embolism. Furthermore, the hazards of immunosuppression and chronic graft rejection are avoided.     

Effectiveness of transesophageal echocardiography in diagnosing complete rupture of the papillary muscle after acute myocardial infarction

We reviewed a case undergoing emergency surgery for acute post-infarction papillary muscle rupture. The patient was a 79-year-old woman transferred to our hospital with cardiogenic shock who required endotracheal intubation. The acute myocardial infarction diagnosis was based on the electrocardiographic findings. She had developed progressively worsening pulmonary edema. No heart murmur was detected. Transthoracic echocardiography demonstrated hyperdynamic cardiac motion and an intracardiac massive turbulent color Doppler signal, but neither mitral regurgitation nor the ruptured papillary muscle head was demonstrated. Her deteriorating condition precluded cardiac catheterization. We performed transesophageal echocardiography (TEE), which demonstrated massive mitral regurgitation and the ruptured anterior papillary muscle connected to normal chordae tendineae and anterior and commissural leaflets. During systole, the head of the ruptured papillary muscle moved like a whip in the left atrium. Emergency surgery was performed. Complete rupture of the anterior papillary muscle head was found, and the mitral valve was replaced with a porcine bioprosthesis (Mosaic #25). Postoperatively, she was weaned from intra-aortic balloon pumping after 2 days and recovered uneventfully. Postoperative coronary angiography demonstrated no significant coronary arterial stenosis. To make the diagnosis of post-infarction papillary muscle rupture, we recommend immediate TEE.     

Diagnosis and Management of Cerebral Malperfusion Phenomena During Aortic Dissection Repair by Transesophageal Doppler Echocardiographic Monitoring

A bstract Background : Early diagnosis and surgical decision making are the key for survival in acute type A aortic dissection (AAD-A). As such, transesophageal echocardiography (TEE) is a widely accepted tool in the diagnosis of AAD-A. Methods : We used TEE in 49 cases as the sole diagnostic examination of AAD-A since November 1989. It was particularly useful intraoperatively to detect cerebral malperfusion during AAD-A repair. We were able to accurately monitor the blood flow of the aortic arch by using TEE for all patients throughout the operation. Only two patients developed severe cerebral malperfusion after the distal anastomosis was finished under deep hypothermic circulatory arrest. TEE showed that the malperfusion after the bypass was re-established. In both cases the expanded false lumen blocked the true lumen. We immediately switched the perfusion cannula from the femoral artery to the ascending aortic graft to create antegrade flow. Results : The subsequent TEE showed only the flow in the true lumen. One patient recovered without any complication while the other suffered mild, temporary neurological defects. Cerebral malperfusion is a potential catastrophic complication of AAD-A, which may exist before surgery or be caused by the operation itself. Conclusions : We recommend continuous intraoperative TEE to monitor aortic arch flow during these operations. This allows immediate detection of cerebral malperfusion and prompt action can be taken to prevent irreversible brain damage.     

Recruitment maneuver and high PEEP in a patient with severe reperfusion pulmonary edema after pulmonary thromboendarterectomy

Recently open lung approach such as recruitment maneuver and high PEEP has been applied in patients with acute respiratory distress syndrome. We report here a 29-year-old man with chronic pulmonary thromboembolism (CPTE). In this case, recruitment maneuver and high PEEP relieved postoperative respiratory failure. The major complications after pulmonary thromboendarterectomy (PTE) for CPTE are: reperfusion pulmonary edema (RPE), pulmonary hypertension (PH), hypoxia and bronchial bleeding, all of which the patient has demonstrated. Preoperative examination showed high pulmonary artery pressure (85/41, mean 50 mmHg), and high pulmonary vascular resistance predicted poor postoperative course. After PTE, he developed severe RPE, PH, hypoxia and bronchial bleeding, resulting in failed weaning from cardiopulmonary bypass. Therefore he required mechanical support of percutaneous cardiopulmonary support (PCPS). In ICU we repeated recruitment maneuver (PEEP: 30 cmH2O, peak inspiratory pressure: 42 cmH2O, respiratory rate; 15 breaths.min-1, for 1 min) and kept high PEEP (15 cmH2O). After initiating this ventilatory strategy, RPE was gradually relieved, followed by improvement of oxygenation and PH. We successfully weaned him from PCPS 38 hr after surgery and he was discharged alive on the 90 post-operative day. We conclude that recruitment maneuver and high PEEP may be useful for RPE developed after PTE.     

Clinical characteristics of perioperative pulmonary thromboembolism: analysis of 18 patients in Kitasato University Hospital

Clinical characteristics of perioperative pulmonary thromboembolism (PTE) at Kitasato University Hospital in Japan were analyzed. Eighteen patients were documented as apparent diagnosis of PTE which developed perioperatively in the period of 1991-1999. The incidence of PTE was 18 out of approximately 50,000 surgical cases. Mean age of patients was 48 years (range, 21 to 79 years). There were 4 men and 14 women. Perioperative risk factors included obesity with body mass index over 26.4 (6/18), and prolonged bed rest after surgery more than 4 days (6/18). Perioperative PTE tended to occur in patients with laparoscopic cholecystectomy (3/18) and cesarean section (3/18). Seven out of 18 PTE patients died. It should be noted that perioperative PTE is prevalent in patients with risk factors of obesity and prolonged bed rest after surgery, and that laparoscopic cholecystectomy and cesarean section may become additional risk factors in patients who are otherwise healthy young adults.     

Pulmonary venous obstruction after lung transplantation. Diagnostic advantages of transesophageal echocardiography

Abstract: Pulmonary venous vascular complications after lung transplantation are rare and a major cause of morbidity and mortality unless diagnosed and treated early. The epidemiological, diagnostic, and management characteristics of 33 patients (two of them in our hospital) with post‐transplant pulmonary vein obstruction published in the literature were reviewed. We consider of utmost importance to differentiate stenosis from thrombosis as the cause of the obstruction. The angiography, considered the gold standard for diagnosis, was replaced by transesophageal echocardiography (TEE) in 79% of the cases, but no echocardiographic diagnostic criteria were defined. A diameter of the pulmonary veins, with 2D/color TEE, <0.5 cm, peak systolic flow velocity (PSFV) >1 m/s, pulmonary vein‐left atrial pressure gradient (PVLAG) ≥10–12 mmHg, non‐permeable flow through the stenosis and the presence of thrombus at that level, must lead us to suspect this complication. Higher mortality rates were found in unilateral procedures and in women. We consider that TEE must be carried out as part of the intraoperative routine or within the first 24 h of the post‐operative period.