[Acute myocardial infarct in pheochromocytoma crisis. Early coronary angiography findings and echocardiography follow-up]

Cardiovascular Manifestations and Complications of Pheochromocytomas and Paragangliomas

Pheochromocytomas and paragangliomas (PPGLs) are rare neuro-endocrine tumors. The catecholamine surge causes paroxysmal or chronic secondary hypertension. PPGLs may present as hypertensive- or PPGL-crisis with severe life-threatening cardiac and cerebrovascular complications. PPGLs-induced cardiac manifestations have been reported with diagnoses as PPGLs-induced electrocardiogram (ECG) changes “mimicking acute myocardial infarction”, arrhythmias, myocarditis, acute coronary syndrome, dilated cardiomyopathy, and lately as takotsubo syndrome. Critical analysis of these reports reveals that most of these cardiac manifestations have certain features in common. They have a dramatic clinical presentation and are reversible if the disease is treated with appropriate medical therapy and surgical resection of the PPGL tumor. They may have the same repolarization ECG changes irrespective of the clinical cardiac diagnosis, usually associated with mild to moderate elevations of myocardial biomarkers as troponins and normal coronary arteries. The histopathological findings are usually focal or multifocal in the form hypercontracted sarcomeres and contraction band necrosis (myofibrillar degeneration) with subsequent secondary mononuclear cell infiltration. Evidences argue the PPGL caused surge of catecholamines triggers hyperactivation of the sympathetic nervous system with cardiac sympathetic nerve terminal disruption with norepinephrine spillover causing the cardiac complications. A comprehensive review of various reported cardiovascular manifestations and complications of PPGLs are presented.

Pheochromocytoma mimicking an acute myocardial infarction

We report a 42-year-old female who presented with retrosternal pain, dyspnoea and nausea. Electrocardiography suggested a recent anterior myocardial infarction. However, emergency coronary angiography showed normal blood flow through all the coronary arteries. Paroxysmal hypertension raised the suspicion of a pheochromocytoma. Indeed, abdominal ultrasonography and computed tomography revealed a mass in the left adrenal gland. Elevated levels of plasma and urine catecholamines supported the diagnosis of pheochromocytoma. Left adrenalectomy was performed without complications and pathological examination revealed a 5.5 cm pheochromocytoma. After surgery, all antihypertensive medication was discontinued and the blood pressure returned to normal within several days. Currently, the patient is asymptomatic, has normal catecholamine levels and the electrocardiographic signs of ischaemia have resolved entirely. This case illustrates that a rare clinical entity such as pheochromocytoma should be considered in the differential diagnosis of acute coronary syndrome. (Neth Heart J 2007;15:248-51.).

[Cardiogenic shock after adrenalectomy for pheochromocytoma]

A 56 year old patient underwent left-sided adrenalectomy for a benign pheochromocytoma. During surgery, he developed a hypertensive crisis while the tumor was being manipulated. Postoperatively, the patient became hypotensive and developed cardiogenic shock. He remained ventilated and intubated. In the subsequent echocardiography a severely impaired left ventricular function with apical akinesia was observed, while the preoperative echocardiogram was normal. Acute coronary angiography was performed which showed no significant stenoses in the coronary arteries. Apical ballooning was seen in the left ventricular angiogram. On the second postoperative day, echocardiography showed an improved left ventricular function which was almost normalized within the next week. Catecholamine release during a left-sided adrenalectomy for a benign pheochromocytoma was associated with Takotsubo cardiomyopathy complicated by cardiogenic shock.

[Cardiogenic shock in a 61 year old female with recurrent panic attacks]

A 61 year old patient in a severely reduced general condition complaining of epigastric pain was admitted to our emergency room. Because of elevated troponin T and creatine kinase levels and severely reduced left ventricular function as seen in echocardiography as well as negative T-waves in the anterolateral ECG leads we suspected an acute coronary syndrome. The patient underwent coronary angiography after intubation and a coronary artery disease was excluded. The initial therapy included the use of an intraaortic balloon pump, volume and catecholamine administration controlled by a pulmonary artery catheter. Conducting an abdominal ultrasound we detected a mass at the right adrenal gland. The suspected diagnosis of pheochromocytoma was confirmed by elevated catecholamine levels in the urine and a CT scan. After recompensation and subsequent administration of phenoxybenzamine a benign pheochromocytoma was resected. A massive catecholamine secretion due to a pheochromocytoma can lead to a cardiogenic shock and multiple organ failure. In patients with recurrent panic attacks and hypertension a pheochromocytoma should be included in the differential diagnosis.

Large myocardial infarction and a severe spasm of the left coronary artery

In patients presenting with an acute myocardial infarction, normal coronary arteries in the first coronary angiography lead to diagnostic uncertainty. We report the case of a 41-year-old woman with an acute anterior infarction and a severe spasm of the left coronary artery, which was treated with intracoronary nitroglycerine and verapamil. The new technique of contrast-enhanced cardiac magnetic resonance imaging was used to confirm the diagnosis.