DISCUSSION: Unless contraindications exist, thrombolysis remains the first line treatment for massive PE. However, there is a dearth of information on re-evaluation of these patients after thrombolysis and treatment options if thrombolysis fails. One single center, prospective study of 488 patients compared rescue surgical embolectomy versus repeat thrombolysis in patients who failed thrombolytic therapy. They found that surgical embolectomy led to a better in-hospital course in terms of mortality, fatal bleed and recurrent PE. Though early recognition in this high risk group remains a challenge, early transthoracic ECHO to monitor RV strain post thrombolysis may identify patients at higher risk of thrombolysis failure. Further clinical studies are needed to answer these questions.