Cardiac pheochromocytoma

Combination of cardiac and carotid glomus tumour: a rare case report

The most common tumour of the heart is myxoma but paraganglioma (also called glomus tumour in extracardiac sites) in the cardiac position is the rarest of them. While this tumour accounts for 0.8% of all primary benign tumours, the combination of both neoplasms is an exceedingly rare occurrence. Herein, we present a case of combined carotid glomus tumour and left atrial paraganglioma tumour in which respiratory distress was the presenting symptom of cardiac type but carotid tumour was asymptomatic. The case underwent a two-step resection of the neck and cardiac mass with an uncomplicated postoperative course and in the 1year follow-up, no recurrence of tumour in both sites was found on physical exam and imaging studies.

Anaesthetic management of cardiac phaeochromocytoma: A case series

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Primary cardiac phaeochromocytoma is a rare form of catecholamine-secreting heart tumour rarely encountered by anaesthetists.

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We present a single centre case series of four cardiac phaeochromocytoma surgical excisions.

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Perioperative management may require aggressive alpha and cautious beta-adrenergic blockage.

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Intraoperative management requires careful use of vasoactive medications and fluids.

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We advocate for the use of cardiac pulmonary bypass when excising cardiac phaeochromocytoma.

Introduction

Primary cardiac phaeochromocytoma is uncommon, with few anaesthetists encountering this rare pathology in clinical practice. Further, there is little information available on the detailed intraoperative and postoperative haemodynamics and principles of the anaesthetic management of this condition.

Presentation of case

We present a retrospective, single-centre case series of four patients with cardiac phaeochromocytoma who presented for surgical excision. We describe the perioperative evaluation and management of these patients, consideration of the requirements for cardiopulmonary bypass, and the analgesic and pharmacologic interventions needed to maintain stable perioperative and intraoperative haemodynamics.

Discussion

Octreotide scintigraphy, in addition to echocardiography, cardiac MRI and coronary angiography proved vital in the preoperative evaluation of these patients. Preoperative anaesthetic management of cardiac phaeochromocytoma involved alpha-adrenergic blockade, judicious beta-adrenergic blockade and hydration. Intraoperatively, the administration of vasodilatory agents prior to, and vasoconstricting agents with volume therapy after tumour excision, were the key elements of anaesthetic management. Furthermore, we believe that cardiopulmonary bypass plays a pertinent role in cardiac phaeochromocytoma excision and that the risks and benefits of pulmonary artery catheters should be considered before use in these patients.

Conclusion

Management of cardiac phaeochromocytoma is complex and demands careful perioperative planning and management. Perioperative morbidity is common and anaethetists play an important role in achieving a successful outcome for patients who present for excision of cardiac phaeochromocytoma.

Resection of Intrathoracic Paraganglioma With and Without Cardiopulmonary Bypass

BACKGROUND

Intrathoracic paragangliomas (PGLs) are rare tumors. Approximately 50% originate from and around cardiac structures.

METHODS

A retrospective review was made of the perioperative course of patients with intrathoracic PGL resection from 2000 through 2015 at Mayo Clinic in Rochester, Minnesota.

RESULTS

Twenty-two patients underwent PGL resection. Sixteen patients (73%) had functioning tumors (11, noradrenergic; 4, mixed noradrenergic and dopaminergic; 1, dopaminergic). Patients with functioning tumors received preoperative adrenergic blockade: 15 (68%), α_1,2-adrenergic receptor antagonist; 4 (18%), α₁-adrenergic receptor antagonists; and 13 (59%) metyrosine. Six patients with nonfunctioning tumors had no adrenergic blockade. Twelve patients had tumor resection without cardiopulmonary bypass-9 for PGL associated with the great vessels, 2 for PGL with pericardial involvement, and 1 for PGL in right atrioventricular groove. Ten patients required cardiopulmonary bypass; for 9, the tumor involved cardiac structures and for 1, it involved ascending aorta and proximal aortic arch. Of these, 1 patient had uncontrollable bleeding and died intraoperatively. Other than this single death, there were no inhospital major cardiac or pulmonary complications. Median follow-up was 8.2 years (range, 2.1 to 17.2). Six patients subsequently had metastatic disease, and of them, 1 died 6 years after the operation.

CONCLUSIONS

In this series, 73% of intrathoracic PGLs were functional and involved noradrenergic, mixed noradrenergic and dopaminergic, or pure dopaminergic secretion. Cardiac and pericardial paraganglioma resection may require cardiopulmonary bypass. Although intraoperative bleeding in most complex cases may be uncontrollable, as for 1 of our patients, those who survived hospital discharge had favorable long-term outcomes.

Right Atrial Paraganglioma: An Extremely Rare Primary Cardiac Neoplasm Mimicking Myxoma

In this report, we present a case of 35-year-old lady who had presented with atypical chest pain and exertional breathlessness for past six months. Transthoracic and transesophageal echocardiograms showed a well-circumscribed, echo-dense mass in the right atrium, attached to the interatrial septum at the level of atrioventricular junction and in the vicinity of coronary sinus ostium. She underwent successful resection of the cardiac mass. Histopathology revealed paraganglioma, which was reconfirmed by immunohistochemistry study. This represents an extremely rare presentation as primary cardiac tumors are 20-times less common than metastatic tumors and paraganglioma is one of the rarest primary cardiac tumors, accounting for < 1% of all cases.

Transthoracic echocardiographic features of cardiac pheochromocytoma: a single-institution experience

BACKGROUND

Cardiac pheochromocytoma is extremely rare. Previous papers usually are reports of a single case. Transthoracic echocardiography (TTE) offers a useful option, but the features of cardiac pheochromocytoma on TTE have not been favorably reported. In this study, the findings of cardiac pheochromocytoma on TTE in nine cases were presented.

METHODS

TTE images (especially two-dimensional ultrasound) of nine patients with cardiac pheochromocytomas were analyzed retrospectively and compared with the findings from surgery.

RESULTS

Among the nine patients with cardiac pheochromocytomas identified in Peking Union Medical College Hospital (PUMCH) clinical and echocardiographic database, TTE identified one cardiac tumor in seven cases (77.8%), two cardiac tumors in one case (11.1%), and a false-negative result in another (11.1%). Cardiac pheochromocytomas were usually located on the base of the heart, near the origin of great arteries. The tumors were usually round or ovoid, ranging from 1.4 cm to 7.7 cm in diameter, with homogeneous and moderate echoes and low activity. They could press or invade surrounding cardiac structures and influence hemodynamics. In this study the majority of cardiac pheochromocytoma seemed marginated and appeared to be encapsulated on TTE. Apical four-chamber view and parasternal short-axis view of the aortic valve were most effective in identifying cardiac pheochromocytomas. The findings on TTE were similar to those from surgical procedures.

CONCLUSION

Cardiac pheochromocytomas presented characteristic TTE appearances in aspect of location, size, texture, and shape of tumors. Understanding of these characteristics on TTE can help correctly recognize this extremely rare disease.

Cardiac Paraganglioma Presenting With Acute Myocardial Infarction and Stroke

We report an unusual presentation of cardiac paraganglioma with acute myocardial infarction and stroke induced by exercise and review the literature regarding this rare cardiac tumor.

Cardiac Pheochromocytomas Detected by Tc-99m-Hydrazinonicotinyl-Tyr3-Octreotide (HYNIC-TOC) Scintigraphy

Primary pheochromocytomas of the heart are extremely rare tumors and difficult to diagnose. Iodine labeled metaiodobenzylguanidine (MIBG) is the first choice of the nuclear medicine modality in the evaluation of adrenal pheochromocytoma. However, the sensitivity of MIBG in the diagnosis of extraadrenal pheochromocytoma is less optimal. In this preliminary report, the efficacy of octreotide scintigraphy using Tc-99m labeled hydrazinonicotinyl-Tyr3-octreotide (HYNIC-TOC) in the evaluation of primary cardiac pheochromocytoma was assessed.