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Gruyters I, Stessel B, Yilmaz A, Vekemans K, Heye S, Timmermans P, Vandenbrande J. Surgical adrenalectomy during rescue Extracorporeal Life Support for pheochromocytoma induced cardiogenic shock: a case report. ACTA ANAESTHESIOLOGICA BELGICA 2021. [DOI: 10.56126/72.4.4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Introduction : Pheochromocytoma, a rare catecholamine-producing tumor, has been described to provoke stress-induced Takotsubo-like cardiomyopathy and even severe refractory cardiogenic shock. In this case report, venoarterial extracorporeal membrane oxygenation (VA-ECMO) was used for hemodynamic stabilization and was continued during the resection of a large neuroendocrine tumor.
Description : A 69-year old male, recently diagnosed with a pheochromocytoma, was referred to our center because of severe cardiogenic shock after induction of anesthesia for resection of the mass. Despite adequate alpha-and beta-adrenergic blockade for one month, he developed malignant hypertension with subsequently hemodynamic collapse. After successful cardiopulmonary resusci-tation he developed pulmonary oedema with severe hypoxemia and persistent hemodynamic lability. On arrival in our hospital, echocardiography revealed significant left ventricular impairment. Decision was made to commence him on VA-ECMO for a refractory cardiogenic shock with severe pulmonary oedema. Because of persistent blood pressure swings despite VA-ECMO and beta-adrenergic blockade, we decided to remove the tumor on mechanical circulatory support by an open surgical approach the next day. After clamping of the adrenal circulation, the patient experienced profound hypotension requiring high doses of epinephrine and a methylene blue infusion. Surgical resection was successful but complicated by a postoperative bleeding for which the patient underwent an emergent endovascular embolization of an adrenal artery. Over the next days, there was progressive cardiac recovery and the patient was weaned off VA-ECMO on the fourth postoperative day. The patient was discharged from the intensive care 27 days after admission and left the hospital on day 30.
Discussion: VA-ECMO seems to be a feasible last resort therapy in refractory cardiogenic shock induced by pheochromocytoma crisis as suggested by a high survival rate in literature. Despite its support benefit during this type of shock, surgical removal of the tumor is rarely done with mechanical circulatory support and heparinization.
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Choudhary M, Chen Y, Friedman O, Cuk N, Ben-Shlomo A. Pheochromocytoma Crisis Presenting With ARDS Successfully Treated With ECMO-Assisted Adrenalectomy. AACE Clin Case Rep 2021; 7:310-314. [PMID: 34522771 PMCID: PMC8426613 DOI: 10.1016/j.aace.2021.03.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Revised: 03/15/2021] [Accepted: 03/16/2021] [Indexed: 01/19/2023] Open
Abstract
Objective Pheochromocytoma (PCC) crisis caused by acute catecholamine release from an adrenal PCC or extra-adrenal paraganglioma can be difficult to diagnose and may require an unconventional management strategy to achieve good outcomes. We describe a case of PCC crisis presenting with acute respiratory distress syndrome (ARDS) that resolved with stabilization on veno-venous (VV) extracorporeal membrane oxygenation (ECMO) during adrenalectomy. Case Description A 30-year-old man with a history of severe alcohol use disorder and a prior hospital admission for alcohol withdrawal syndrome presented with sudden-onset hemoptysis, altered mental status, and severe dyspnea that rapidly deteriorated to ARDS requiring ECMO support. He demonstrated hemodynamic collapse after cannulation for VV-ECMO and stabilized after conversion to veno-arterial-ECMO, but ARDS persisted and he developed acute renal failure. Computed tomography without contrast done as part of work-up for a presumed infection revealed a 6.9 × 6.4 cm right adrenal mass suspicious for pheochromocytoma. Plasma and random urine metanephrine levels were markedly elevated. ARDS persisted despite α- and β-adrenoreceptor blockade, and he underwent laparoscopic right adrenalectomy with VV-ECMO support. Pathology confirmed PCC with intermediate risk for malignancy. Postoperatively, he was weaned off respiratory and renal support within 10 days, showed rapid clinical improvement, and was discharged 1 month later. Conclusion This case highlights diagnostic and management challenges associated with patients with PCC crisis presenting with ARDS. A multidisciplinary team approach is critical to identifying appropriate treatment strategies.
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Affiliation(s)
- Manita Choudhary
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
| | - Yufei Chen
- Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, California
| | - Oren Friedman
- Women's Guild Lung Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Natasha Cuk
- Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - Anat Ben-Shlomo
- Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, California
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3
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Matteucci M, Kowalewski M, Fina D, Jiritano F, Meani P, Raffa GM, Aldobayyan I, Beghi C, Maessen J, Lorusso R. Extracorporeal life support for phaeochromocytoma-induced cardiogenic shock: a systematic review. Perfusion 2021; 35:20-28. [PMID: 32397890 DOI: 10.1177/0267659120908413] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Phaeochromocytoma is a catecholamine-secreting tumour associated with clinical presentation ranging from paroxysmal hypertension to intractable cardiogenic shock. Extracorporeal life support, in veno-arterial mode, application in refractory acute heart dysfunction is sharply increasing worldwide. However, its clinical utility in phaeochromocytoma-induced cardiogenic shock remains still unclear. METHODS A systematic review of published reports was performed in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Statement. Searches were accomplished on PubMed, Embase and Google Scholar to identify articles describing the use of extracorporeal life support in the setting of phaeochromocytoma-induced cardiogenic shock (PROSPERO: CRD42019125225). RESULTS Thirty-five reports, including 62 patients supported with extracorporeal life support because of intractable phaeochromocytoma crisis, were included for the analysis. Almost all the subjects underwent peripheral cannulation for extracorporeal life support. The median duration of the mechanical circulatory support was 5 days, and most of the patients recovered normal myocardial function (left ventricular ejection fraction ⩾50%). In-hospital survival was 87%. Phaeochromocytoma was removed surgically during extracorporeal life support in 10 patients (16%), while in the remaining after haemodynamic stabilization and weaning from the mechanical support. CONCLUSION Successful management of phaeochromocytoma-induced cardiogenic shock depends on prompt recognition and immediate treatment of shock. In this scenario, extracorporeal life support may play a significant role allowing cardiac and end-organ recovery and giving time for accurate diagnosis and specific treatment.
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Affiliation(s)
- Matteo Matteucci
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands.,Department of Cardiac Surgery, Circolo Hospital, University of Insubria, Varese, Italy
| | - Mariusz Kowalewski
- Clinical Department of Cardiac Surgery, Central Clinical Hospital of the Ministry of Interior in Warsaw, Warsaw, Poland
| | - Dario Fina
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands.,IRCCS Policlinico San Donato, University of Milan, Milan, Italy
| | - Federica Jiritano
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands.,Department of Cardiac Surgery, University Magna Graecia of Catanzaro, Catanzaro, Italy
| | - Paolo Meani
- Department of Cardiology, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Giuseppe M Raffa
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands.,Department for the Treatment and Study of Cardiothoracic Diseases and Cardiothoracic Transplantation, Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Palermo, Italy
| | - Ibrahim Aldobayyan
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands
| | - Cesare Beghi
- Department of Cardiac Surgery, Circolo Hospital, University of Insubria, Varese, Italy
| | - Jos Maessen
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Roberto Lorusso
- Department of Cardiothoracic Surgery, Heart and Vascular Centre, Maastricht University Medical Centre (MUMC), Maastricht, The Netherlands.,Cardiovascular Research Institute Maastricht (CARIM), Maastricht University, Maastricht, The Netherlands
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Shock Team Approaches in Managing Cardiogenic Shock—Intersection Between Critical Care and Advanced Heart Failure and Transplant Cardiology. CURRENT TREATMENT OPTIONS IN CARDIOVASCULAR MEDICINE 2020. [DOI: 10.1007/s11936-020-00820-2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Bouabdallaoui N, Bouchard D, Jolicoeur EM, Chronopoulos A, Garneau PY, Lamarche Y. Extracorporeal membrane oxygenation in pheochromocytoma-induced cardiogenic shock. Asian Cardiovasc Thorac Ann 2017; 26:314-316. [PMID: 28823181 DOI: 10.1177/0218492317727995] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Extracorporeal membrane oxygenation has been extensively used for cardiopulmonary support in cardiogenic shock. However, its clinical value in the management of pheochromocytoma crisis remains unclear. We report a rare case of life-threatening cardiogenic shock managed with peripheral venoarterial extracorporeal membrane oxygenation combined with endovascular left ventricular venting, in a 40-year-old female patient, in the setting of unknown adrenal pheochromocytoma. We highlight the life-saving role of extracorporeal membrane oxygenation in undiagnosed endocrine emergencies, allowing cardiac and end-organ recovery, and giving time for accurate diagnosis and specific treatment in such unusual situations.
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Affiliation(s)
- Nadia Bouabdallaoui
- 1 Department of Medicine, Montreal Heart Institute, 25465 Université de Montréal, Montreal, Canada
| | - Denis Bouchard
- 2 Department of Surgery, Montreal Heart Institute, 25465 Université de Montréal, Montreal, Canada
| | - E Marc Jolicoeur
- 1 Department of Medicine, Montreal Heart Institute, 25465 Université de Montréal, Montreal, Canada
| | | | - Pierre Y Garneau
- 4 Department of Surgery, Hôpital du Sacré-Coeur de Montréal, Montreal, Canada
| | - Yoan Lamarche
- 2 Department of Surgery, Montreal Heart Institute, 25465 Université de Montréal, Montreal, Canada
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Hekimian G, Kharcha F, Bréchot N, Schmidt M, Ghander C, Lebreton G, Girerd X, Tresallet C, Trouillet JL, Leprince P, Chastre J, Combes A, Luyt CE. Extracorporeal membrane oxygenation for pheochromocytoma-induced cardiogenic shock. Ann Intensive Care 2016; 6:117. [PMID: 27896787 PMCID: PMC5126035 DOI: 10.1186/s13613-016-0219-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2016] [Accepted: 11/21/2016] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND Pheochromocytoma, a rare catecholamine-producing tumor, might provoke stress-induced Takotsubo-like cardiomyopathy and severe cardiogenic shock. Because venoarterial-extracorporeal membrane oxygenation (VA-ECMO) rescue of pheochromocytoma-induced refractory cardiogenic shock has rarely been reported, we reviewed our ICU patients' presentations and outcomes. METHODS All pheochromocytoma-induced refractory cardiogenic shock cases managed with VA-ECMO (January 2007-March 2015) were prospectively included and reviewed. We also performed a systematic review on this topic. RESULTS Nine patients (7 women, 2 men; 31-51 [median, 43 (IQR 36-49) years old]) were included; none had a previously known pheochromocytoma. Six of them had medical histories suggestive of the diagnosis: palpitations and headaches for several months for four, multiple endocrine neoplasia syndrome type 1 for one and recurrent Takotsubo disease for one; at hospital admission, all were hypertensive despite cardiogenic shock. Three others had an identified surgical triggering factor. All nine patients rapidly developed refractory cardiogenic shock with very severe left ventricular (LV) impairment (LV ejection-fraction range 5-20%; LV outflow-tract velocity-time integral range 3-8 cm). Seven patients' abdominal computed tomography scans showed pheochromocytoma-suggestive adrenal gland tumors (no scan during ICU stay for 2). Despite VA-ECMO implantation, three patients died of refractory multiple organ failure. For the six others, myocardial function improved and ECMO was removed 3-7 days post-implantation; α- and β-blockers were progressively introduced. Five survivors underwent pheochromocytoma excision 3 weeks-4 months post-ICU discharge, with satisfactory outcomes. One patient, whose pheochromocytoma was diagnosed 1 year after the index event, underwent uneventful surgical adrenalectomy. Systematic review retrieved 40 cases of pheochromocytoma-induced cardiogenic shock requiring mechanical support (mostly ECMO), with a mortality rate of 7%. Pheochromocytoma was removed surgically after mechanical support weaning in 31 patients and during mechanical support in 5. Four were not operated. CONCLUSIONS Pheochromocytoma is a rare but reversible cause of cardiogenic shock amenable to VA-ECMO rescue. Adrenal gland imaging should be obtained for all patients with unexplained cardiogenic shock. Lastly, it might be safer to perform adrenalectomy several weeks after the initial catastrophic presentation, once recovery of LV systolic function is complete.
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Affiliation(s)
- Guillaume Hekimian
- Intensive Care Unit, Institute of Cardiology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France. .,UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France.
| | - Fatima Kharcha
- Institute of Endocrinology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Nicolas Bréchot
- Intensive Care Unit, Institute of Cardiology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Matthieu Schmidt
- Intensive Care Unit, Institute of Cardiology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Cécile Ghander
- Institute of Endocrinology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Guillaume Lebreton
- Department of Cardiac and Thoracic Surgery, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Xavier Girerd
- Institute of Endocrinology, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Christophe Tresallet
- Department of General and Endocrine Surgery, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Jean-Louis Trouillet
- Intensive Care Unit, Institute of Cardiology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Pascal Leprince
- Department of Cardiac and Thoracic Surgery, Pierre et Marie Curie Sorbonne Université, APHP, Groupe Hospitalier Pitié-Salpêtrière, Paris, France
| | - Jean Chastre
- Intensive Care Unit, Institute of Cardiology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Alain Combes
- Intensive Care Unit, Institute of Cardiology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
| | - Charles-Edouard Luyt
- Intensive Care Unit, Institute of Cardiology, Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Paris, France.,UPMC Université Paris 06, INSERM, UMRS_1166-ICAN Institute of Cardiometabolism and Nutrition, Paris, France
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Dang Van S, Hamy A, Hubert N, Fouquet O. Cardiogenic shock induced by a voluminous phaeochromocytoma rescued by concomitant extracorporeal life support and open left adrenalectomy. Eur J Cardiothorac Surg 2016; 50:782-783. [DOI: 10.1093/ejcts/ezw122] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2015] [Revised: 03/01/2016] [Accepted: 03/08/2016] [Indexed: 11/14/2022] Open
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8
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Banfi C, Guerbaai RA, Giraud R, Ennezat PV, Juthier F, Rousse N, Bendjalid K, Vincentelli A. Role of endomyocardial biopsy in the diagnostic procedure of pheochromocytoma induced cardiogenic shock. Int J Cardiol 2016; 206:138. [PMID: 26797156 DOI: 10.1016/j.ijcard.2016.01.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2015] [Accepted: 01/02/2016] [Indexed: 11/17/2022]
Affiliation(s)
- Carlo Banfi
- Division of Cardiovascular Surgery, Geneva University Hospitals, Geneva Hemodynamic Research Group, Faculty of Medicine, University of Geneva, Switzerland.
| | - Raphaëlle-Ashley Guerbaai
- Department of Cardiology, Centre Hospitalier Regional et Universitaire de Grenoble, Grenoble, France
| | - Raphaël Giraud
- Intensive Care Service, Geneva University Hospitals, Geneva Hemodynamic Research Group, Faculty of Medicine, University of Geneva, Switzerland
| | - Pierre-Vladimir Ennezat
- Department of Cardiology, Centre Hospitalier Regional et Universitaire de Grenoble, Grenoble, France
| | - Francis Juthier
- Department of Cardiac Surgery Lille University Hospital, Institute Pasteur Lille, EGID, INSERM UMR 1011, University of Lille 2, France
| | - Natacha Rousse
- Department of Cardiac Surgery Lille University Hospital, Institute Pasteur Lille, EGID, INSERM UMR 1011, University of Lille 2, France
| | - Karim Bendjalid
- Intensive Care Service, Geneva University Hospitals, Geneva Hemodynamic Research Group, Faculty of Medicine, University of Geneva, Switzerland
| | - André Vincentelli
- Department of Cardiac Surgery Lille University Hospital, Institute Pasteur Lille, EGID, INSERM UMR 1011, University of Lille 2, France
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Shawa H, Bajaj M, Cunningham GR. Pheochromocytoma-induced atrial tachycardia leading to cardiogenic shock and cardiac arrest: resolution with atrioventricular node ablation and pacemaker placement. Tex Heart Inst J 2014; 41:660-3. [PMID: 25593537 DOI: 10.14503/thij-13-3692] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
Pheochromocytoma should be considered in young patients who have acute cardiac decompensation, even if they have no history of hypertension. Atrioventricular node ablation and pacemaker placement should be considered for stabilizing pheochromocytoma patients with cardiogenic shock due to atrial tachyarrhythmias. A 38-year-old black woman presented with cardiogenic shock (left ventricular ejection fraction, <0.15) that did not respond to the placement of an intra-aortic balloon pump. A TandemHeart(®) Percutaneous Ventricular Assist Device was inserted emergently. After atrioventricular node ablation and placement of a temporary pacemaker, the TandemHeart was removed. Computed tomography of the abdomen revealed a pheochromocytoma. After placement of a permanent pacemaker, the patient underwent a right adrenalectomy. This is, to our knowledge, the first reported case of pheochromocytoma-induced atrial tachyarrhythmia that led to cardiogenic shock and cardiac arrest unresolved by the placement of 2 different ventricular assist devices, but that was completely reversed by radiofrequency ablation of the atrioventricular node and the placement of a temporary pacemaker. We present the patient's clinical, laboratory, and imaging findings, and we review the relevant literature.
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MESH Headings
- Adrenal Gland Neoplasms/complications
- Adrenal Gland Neoplasms/diagnosis
- Adrenal Gland Neoplasms/surgery
- Adrenalectomy
- Adult
- Atrioventricular Node/physiopathology
- Atrioventricular Node/surgery
- Cardiac Pacing, Artificial
- Catheter Ablation
- Electrocardiography
- Female
- Heart Arrest/diagnosis
- Heart Arrest/etiology
- Heart Arrest/therapy
- Humans
- Pacemaker, Artificial
- Pheochromocytoma/complications
- Pheochromocytoma/diagnosis
- Pheochromocytoma/surgery
- Predictive Value of Tests
- Shock, Cardiogenic/diagnosis
- Shock, Cardiogenic/etiology
- Shock, Cardiogenic/therapy
- Tachycardia, Supraventricular/diagnosis
- Tachycardia, Supraventricular/etiology
- Tachycardia, Supraventricular/physiopathology
- Tachycardia, Supraventricular/therapy
- Tomography, X-Ray Computed
- Treatment Outcome
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Flam B, Broomé M, Frenckner B, Bränström R, Bell M. Pheochromocytoma-Induced Inverted Takotsubo-Like Cardiomyopathy Leading to Cardiogenic Shock Successfully Treated With Extracorporeal Membrane Oxygenation. J Intensive Care Med 2014; 30:365-72. [DOI: 10.1177/0885066614552992] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2014] [Accepted: 06/13/2014] [Indexed: 01/27/2023]
Abstract
Pheochromocytoma classically displays a variety of rather benign symptoms, such as headache, palpitations, and sweating, although severe cardiac manifestations have been described. We report a case of pheochromocytoma-induced inverted takotsubo-like cardiomyopathy leading to shock and cardiac arrest successfully treated with extracorporeal membrane oxygenation (ECMO) as a bridge to pharmacological therapy and curative adrenalectomy. A previously healthy 46-year-old woman presented to the emergency department with abdominal pain, dyspnea, nausea, and vomiting. Clinical evaluation revealed cardiorespiratory failure with hypoxia and severe metabolic acidosis. Computed tomography (CT) scan showed pulmonary edema and a left adrenal mass. Transthoracic echocardiography (TTE) displayed severe left ventricular dysfunction with inverted takotsubo contractile pattern. Despite mechanical ventilation and inotropic and vasopressor support, asystolic cardiac arrest ensued. The patient was resuscitated using manual chest compressions followed by venoarterial ECMO. Repeated TTEs demonstrated resolution of the cardiomyopathy within a few days. Laboratory results indicated transient renal and hepatic dysfunction, and CT scan of the brain displayed occipital infarctions. Biochemical testing and radionuclide scintigraphy confirmed a pheochromocytoma. Pharmacological adrenergic blockade was instituted prior to delayed adrenalectomy after which the diagnosis was histopathologically verified. The patient recovered after rehabilitation. We conclude that pheochromocytoma should be considered in patients presenting with unexplained cardiovascular compromise, especially if they display (inverted) takotsubo contractile pattern. Timely, adequate management might involve ECMO as a bridge to pharmacological therapy and curative surgery.
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Affiliation(s)
- Benjamin Flam
- Department of Anesthesiology and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden
| | - Michael Broomé
- ECMO Department, Karolinska University Hospital, Stockholm, Sweden
- Section of Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Björn Frenckner
- ECMO Department, Karolinska University Hospital, Stockholm, Sweden
- Department of Pediatric Surgery, Astrid Lindgren Children’s Hospital, Karolinska University Hospital, Stockholm, Sweden
- Division of Pediatric Surgery, Department of Women’s and Children’s Health, Karolinska Institutet, Stockholm, Sweden
| | - Robert Bränström
- Department of Breast and Endocrine Surgery, Karolinska University Hospital, Stockholm, Sweden
- Endocrine and Sarcoma Surgery Unit, Department of Molecular Medicine and Surgery, Karolinska Institutet, Stockholm, Sweden
| | - Max Bell
- Department of Anesthesiology and Intensive Care, Karolinska University Hospital, Solna, Stockholm, Sweden
- Section of Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
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Contargyris C, Nee L, Saby C, Kerbaul F, Peytel E. Choc cardiogénique révélant un phéochromocytome traité par assistance circulatoire. ACTA ACUST UNITED AC 2012; 31:965-8. [DOI: 10.1016/j.annfar.2012.10.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2012] [Accepted: 10/09/2012] [Indexed: 01/09/2023]
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Araújo SDA, do Carmo PAS, Paulino E, Borges IN, Rocha LOS. Pheochromocytoma-induced shock: a case report. AUTOPSY AND CASE REPORTS 2012; 2:21-30. [PMID: 31528576 PMCID: PMC6735568 DOI: 10.4322/acr.2012.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2012] [Accepted: 08/01/2012] [Indexed: 01/09/2023] Open
Abstract
Because of its rarity, together with the variability and nonspecificity of its signs and symptoms, pheochromocytoma, a tumor arising from chromaffin cells, creates an unlucky paradox: it is often missed but only rarely found. Besides the association with arterial hypertension, often in the form of paroxysmal attacks, pheochromocytoma may also be associated, in up to 40% of cases, with orthostatic hypotension which, when present, provides a clue to the diagnosis of the tumor. Far more rare (about 2% of cases) is the clinical presentation in the form of shock, a possibility that, among other attributes, justifies the epithet “the great mimic” applied to the neoplasia. The authors report the case of a 51-year-old hypertensive woman whose death was erroneously attributed to septic shock. Autopsy disclosed an unsuspected left adrenal bulky pheochromocytoma with areas of hemorrhage and extensive central necrosis, pronounced pulmonary edema, left ventricular mural thrombus, and histological evidence of acute myocardial injury.
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Affiliation(s)
- Stanley de Almeida Araújo
- Department of Pathology and Forensic Medicine - Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte/MG - Brasil
| | - Paula Alves Santos do Carmo
- Department of Pathology and Forensic Medicine - Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte/MG - Brasil
| | - Eduardo Paulino
- Department of Pathology and Forensic Medicine - Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte/MG - Brasil
| | - Isabela Nascimento Borges
- Internal Medicine Service - Hospital das Clínicas da Universidade Federal de Minas Gerais, Belo Horizonte/MG - Brasil
| | - Luiz Otávio Savassi Rocha
- Department of Internal Medicine - Faculdade de Medicina da Universidade Federal de Minas Gerais, Belo Horizonte/MG - Brasil
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13
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Banfi C, Juthier F, Ennezat PV, de Saint Denis T, Carnaille B, Leteurtre E, Prat A, Vincentelli A. Central Extracorporeal Life Support in Pheochromocytoma Crisis. Ann Thorac Surg 2012; 93:1303-5. [DOI: 10.1016/j.athoracsur.2011.09.018] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2011] [Revised: 07/07/2011] [Accepted: 09/02/2011] [Indexed: 11/25/2022]
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14
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Une cause rare de choc cardiogénique réfractaire nécessitant une assistance circulatoire : le paragangliome sécrétant. ACTA ACUST UNITED AC 2011; 30:363-5. [DOI: 10.1016/j.annfar.2011.01.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2010] [Accepted: 01/28/2011] [Indexed: 11/22/2022]
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Raikhelkar J, Anyanwu A, Gist RS, Somal J, Mechanick JI, Scher C, Scurlock C. Pheochromocytoma Presenting as Severe Biventricular Failure Requiring Insertion of a Biventricular Assist Device. J Cardiothorac Vasc Anesth 2010; 24:985-7. [DOI: 10.1053/j.jvca.2009.06.008] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2009] [Indexed: 11/11/2022]
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Carey M, Carter J, Nesbitt I. Phaeochromocytoma Crisis Presenting under Anaesthesia with Profound Left Ventricular Failure — Successful Treatment with Intra-Aortic Balloon Pump. J Intensive Care Soc 2010. [DOI: 10.1177/175114371001100311] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
A patient presented with a phaeochromocytoma crisis during routine anaesthesia for minor ENT surgery. The ensuing cardiac arrest and profound left ventricular failure were successfully treated with an intra-aortic balloon pump until alpha blockade with phenoxybenzamine took effect. The rapid diagnosis of phaeochromocytoma and management of phaeochromocytoma crisis are reviewed.
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Affiliation(s)
- Michelle Carey
- Michelle Carey Consultant in Anaesthesia and Intensive Care Medicine, The James Cook University Hospital, Middlesbrough
| | - Jim Carter
- Jim Carter Consultant Anaesthetist, Freeman Hospital, Newcastle upon Tyne
| | - Ian Nesbitt
- Ian Nesbitt Consultant in Anaesthesia and Intensive Care Medicine, Freeman Hospital, Newcastle upon Tyne
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Abstract
BACKGROUND A 27-year-old male presented with exercise-related symptoms of chest tightness, palpitations, breathlessness and severe headache, with occasional nausea, dizziness, and blurred vision. Apart from a family history of coronary artery disease there was no other medical history of note. INVESTIGATIONS Clinical examination, treadmill exercise test (Bruce protocol), electrocardiography, MRI of the abdomen, blood tests, chest radiography, coronary angiography, two-dimensional echocardiography, transesophageal echocardiography, microscopy of the tumor, (131)iodine metaiodobenzylguanidine scan. DIAGNOSIS Pheochromocytoma myocarditis. MANAGEMENT Intra-aortic balloon pump, levosimendan and dobutamine infusion, alpha-blockade with phentolamine, surgical removal of the pheochromocytoma, Levitronix (Levitronix LLC, Waltham, MA) left ventricular assist device implantation.
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Shih JA, Williams Jr BR, Merlino J, Butler J, Smith A, Book W, Laskar S. Rapid Onset and Resolution of Cardiogenic Shock in a Patient With Pheochromocytoma. ACTA ACUST UNITED AC 2009; 15:151-3. [DOI: 10.1111/j.1751-7133.2009.00077.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Park SM, Kim DH, Kwak YT, Jeong IK, Cho JM, Jin ES, Kim CJ. Pheochromocytoma-induced cardiogenic shock rescued by percutaneous cardiopulmonary bypass system. Circ J 2009; 73:1753-5. [PMID: 19145042 DOI: 10.1253/circj.cj-08-0287] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Pheochromocytoma is a rare cause of cardiogenic shock. Clinical management is directed at reducing the heart rate while maintaining blood pressure. However, medical treatment is often unsuccessful because of the high endogenous catecholamine level and low cardiac output. Percutaneous cardiopulmonary bypass system is a circulatory device that allows for safer use of heart-rate-reducing agents, which is advantageous when used early in the course of the cardiogenic shock induced by pheochromocytoma.
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Affiliation(s)
- Sung-Min Park
- Department of Thoracic and Cardiovascular Surgery, Kyung Hee University East-West Neo Medical Center, Seoul, Korea.
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Affiliation(s)
- James D. Newton
- From the Department of Cardiology, John Radcliffe Hospital, Oxford, UK
| | - Shahzad Munir
- From the Department of Cardiology, John Radcliffe Hospital, Oxford, UK
| | - Ravinay Bhindi
- From the Department of Cardiology, John Radcliffe Hospital, Oxford, UK
| | - Oliver Ormerod
- From the Department of Cardiology, John Radcliffe Hospital, Oxford, UK
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Huang JH, Huang SC, Chou NK, Ko WJ, Chen YS, Wang SS. Extracorporeal membrane oxygenation rescue for cardiopulmonary collapse secondary to pheochromocytoma: report of three cases. Intensive Care Med 2008; 34:1551-2. [DOI: 10.1007/s00134-008-1117-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2008] [Indexed: 11/30/2022]
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Chao A, Yeh YC, Yen TS, Chen YS. Phaeochromocytoma crisis--a rare indication for extracorporeal membrane oxygenation. Anaesthesia 2008; 63:86-8. [PMID: 18086076 DOI: 10.1111/j.1365-2044.2007.05251.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
We report on a case of phaeochromocytoma whose initial presentation mimicked an acute myocardial infarction. Veno-arterial extracorporeal membrane oxygenation was used for the management of refractory cardiogenic shock and massive lung oedema. Suspicion and diagnosis of a phaeochromocytoma were made due to its unique clinical presentation during extracorporeal membrane oxygenation. Stabilisation of the crisis and recovery of cardiopulmonary function were achieved using the support of extracorporeal membrane oxygenation. This case highlights the difficulty in the differential diagnosis of cardiogenic shock secondary to phaeochromocytoma and the important role of extracorporeal membrane oxygenation can have in the successful resuscitation and management of these patients.
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Affiliation(s)
- A Chao
- Department of Anaesthesia and Intensive Care, National Taiwan University Hospital, 7, Chung-Shan S. Road, Taipei, 100, Taiwan.
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Brouwers FM, Eisenhofer G, Lenders JWM, Pacak K. Emergencies caused by pheochromocytoma, neuroblastoma, or ganglioneuroma. Endocrinol Metab Clin North Am 2006; 35:699-724, viii. [PMID: 17127142 DOI: 10.1016/j.ecl.2006.09.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
Pheochromocytoma may lead to important emergency situations, ranging from cardiovascular emergencies to acute abdomen and multiorgan failure. It is vital to think about this disease in any emergency situation when conventional therapy fails to achieve control or symptoms occur that do not fit the initial diagnosis. The importance of keeping this diagnosis in minds is underscored by the fact that, in 50% of pheochromocytoma patients, the diagnosis is initially overlooked. Two other tumors of the sympathetic nervous system, neuroblastoma and ganglioneuroma, are less commonly associated with emergency conditions. If they occur, they are often linked to catecholamine excess, paraneoplastic phenomena, or local tumor mass effect.
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Affiliation(s)
- Frederieke M Brouwers
- Section on Medical Neuroendocrinology, Reproductive Biology and Medicine Branch, National Institute of Child Health and Human Development, Bethesda, MD 20892-1109, USA
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