In pulmonary embolism, multiple facets of clinical appearance with nonspecific symptoms may impede timely and correct diagnosis. Right heart strain is a decisive factor for outcome and ensues the aggressiveness of diagnostic and therapeutic measures. Echocardiography and pulmonary angio-CT secure diagnosis and direct therapy. ICU treatment is mandatory and includes full anticoagulation with circulatory and respiratory support when required. Thrombolysis is the treatment of choice for high-risk patients with persistent hypotension or even cardiogenic shock. The indication for pulmonary embolectomy has been modified to patients with massive right heart failure and contraindication to thrombolytic therapy and hemodynamic instability in spite ongoing thrombolytic treatment and should also be primarily considered when transit thrombi and/or a patent foramen ovale are diagnosed. Embolectomy is performed with cardiopulmonary bypass which provides immediate right ventricular relief, restoration of systemic circulation, and oxygen supply. Postoperative venous Doppler/CT examinations help decide whether a cava filter implantation is indicated. Anticoagulation is continued for at least 3 months and indefinitely in recurrent venous thromboembolism and persistent risk factors.