Successful thrombolysis of submassive pulmonary embolism after bariatric surgery: expanding the indications and addressing the controversies. 
Venous thromboembolic (VTE) disease is a much-feared complication of bariatric surgery.  The most common unexpected cause of death in the morbidly obese patient is pulmonary embolism (PE).  Recent data supports the expanded use of systemic thrombolytics in hemodynamically stable patients with PE and echocardiographic evidence of right ventricular (RV) dysfunction.  We report a morbidly obese 28-year-old female who presented with dyspnea 3 weeks following bariatric surgery.  The patient developed a submassive PE, despite being on low molecular weight (LMW) heparin (dalteparin) postoperatively.  The patient was admitted to the surgical intensive care unit of an urban community teaching hospital and underwent successful thrombolysis.  Although the patient was not hypotensive, she was tachycardic and highly symptomatic.  Spiral CT scanning revealed a large saddle embolism.  Transthoracic echocardiography revealed moderate-to-severe acute RV dysfunction with paradoxical septal motion.  The patient was started on i.v.  heparin followed by an infusion of alteplase 100 mg i.v.  over 2 hours.  She had no mental status changes during the infusion or evidence of hemorrhage.  She had a rapid improvement of her symptoms.  Repeat CT scanning revealed marked resolution of the PE.  She was discharged home in excellent condition.  To our knowledge, this is the first report of systemic thrombolysis for a submassive PE after bariatric surgery in a hemodynamically stable patient with RV dysfunction.  Given the high incidence and morbidity of VTE disease in this population, and the expanding indications for thrombolytic therapy, successful cases such as these should be documented.