Excision of adrenal pheochromocytoma and coronary artery bypass graft surgery with cardiopulmonary bypass

Laparoscopic excision of normotensive variant pheochromocytoma in a case of triple vessel coronary artery disease: The anaesthesia challenge

Pheochromocytomas are catecholamine-secreting tumours arising mostly from the adrenal medulla. With the advancement in surgical and anaesthetic techniques, the incidence of severe morbidity and mortality associated with surgery is low. However, concurrent coronary artery disease and pheochromocytoma continue to be a challenge due to the risk of adverse cardiovascular events. We describe the successful management of pheochromocytoma excision in a patient with coronary artery disease.

A case report of an open aortic valve replacement followed by open adrenalectomy in a patient with symptomatic pheochromocytoma and critical aortic stenosis

Background

Pheochromocytoma is a rare medical condition caused by catecholamine-secreting tumor cells. Operative resection can be associated with significant hemodynamic fluctuations due to the nature of the tumor, as well as associated post-resection vasoplegia. To allow for cardiovascular recovery before surgery, patients require pre-operative alpha-adrenergic blockade, which would be limited in the setting of co-existent severe aortic stenosis. In this report, we describe a patient with severe aortic stenosis and symptomatic pheochromocytoma.

Case presentation

A 51-year-old man with severe aortic stenosis (valve area 0.8 cm²) was found to have a highly active 4 × 4 cm left adrenal pheochromocytoma. Alpha-adrenergic blockade for his pheochromocytoma was limited by syncope in the setting of his aortic stenosis. Open aortic valve replacement (AVR) was performed, followed by adrenalectomy the next day. The perioperative course for each surgical procedure was hemodynamically volatile, exacerbated by severe alcohol withdrawal. During the adrenalectomy, cardiogenic and vasoplegic shock developed immediately after securing the vascular supply to his tumor. This shock was refractory to vasopressin and methylene blue, but responded well to angiotensin II and epinephrine. After both surgeries were completed, his course was further complicated by severe ICU psychosis, ileus, fungal bacteremia, pneumonia/hypoxic respiratory failure and atrial fibrillation. He ultimately recovered and was discharged from the hospital after 38 days.

Conclusion

To our knowledge, this is the first report of surgical AVR and pheochromocytoma resection in a patient with critical aortic stenosis. The appropriate order and timing of surgeries when both these conditions co-exist remains controversial.

Phaeochromocytoma presenting with labile blood pressures following coronary artery bypass grafting

Pheochromocytomas have been reported prior to and during coronary artery bypass surgery. We present a patient with an undiagnosed pheochromocytoma who presented with labile hypertension following coronary artery bypass surgery. This case calls attention to the inclusion of an undiagnosed pheochromocytoma in the differential diagnosis for all patients who develop labile hypertension in the postoperative period following cardiac surgery.

Coronary bypass surgery in the presence of metastatic pheochromocytoma

The hemodynamic management of a patient with a pheochromocytoma presents special challenges due to the episodic release of catecholamines from the tumor, which threatens to provoke a hypertensive crisis. We present a patient with metastatic pheochromocytoma (bone, lung, lymph nodes) who underwent successful coronary artery bypass graft (CABG) surgery following premedication with phenoxybenzamine and metyrosine as well as the use of intraoperative phentolamine for the management of a hypertensive crisis in the operating room.

Coronary artery bypass grafting and concomitant excision of chest wall chondrosarcoma

Coexistence of coronary artery disease and cancer with both requiring surgical treatment at the same time is rare. A 52 year male undergoing elective coronary artery bypass grafting was incidentally discovered to have a large soft tissue mass of variable consistency with cartilaginous elements arising from the right costal margin and adjoining ribs by a broad attachment and protruding into right pleural cavity. Frozen section suggested it to be either a chondrosarcoma or a teratoma. A wide excision of the mass with the adjoining muscle and periosteum along with quadruple coronary artery bypass grafting was done. This report is unusual on account of a) being the first reported case in world literature of concomitant excision of chondrosarcoma and coronary artery bypass grafting and b) the conservative management of the incidentally discovered chondrosarcoma by wide excision rather than chest wall resection with no local recurrence to date. Pathology of chondrosarcoma, in particular, and various management strategies when coronary artery disease and cancer coexist, in general, is discussed.

Preoperative management of the pheochromocytoma patient

Pheochromocytomas are rare neuroendocrine tumors with a highly variable clinical presentation, but they most commonly present as spells of headaches, sweating, palpitations, and hypertension. Patients with pheochromocytoma may develop complicated and potentially lethal cardiovascular and other complications, especially in the setting of diagnostic or interventional procedures (e.g. upon induction of anesthesia or during surgery). The serious and potentially lethal nature of such complications is due to the potent effect of paroxysmal release of catecholamines. Because this warrants prompt diagnosis and treatment, the physician should be aware of the clinical manifestations and complications of catecholamine excess and be able to provide proper preoperative management to minimize catecholamine-related pre-, intra-, and postoperative adverse events. The following clinical scenario and discussion aim to enhance the knowledge of the physician regarding the behavior of pheochromocytoma and to outline current approaches to comprehensive preoperative management of patients suffering from this tumor.

Combined coronary artery bypass grafting and phaeochromocytoma excision

We report two patients who had successful combined coronary artery bypass grafting and excision of phaeochromocytoma. These cases represent the first reports of combined coronary artery bypass grafting and laparoscopic adrenalectomy for phaeochromocytoma and of combined coronary artery bypass grafting and excision of extra-adrenal phaeochromocytoma. With careful peri- and intra-operative management, especially in regard to haemostasis, combined operations for coronary artery disease and phaeochromocytoma are both feasible and safe.

Pheochromocytoma and myocardial infarction

Pheochromocytomas are rare chromaffin cell tumors, 90% of which arise from the adrenal glands. Pheochromocytomas presenting with true myocardial infarction are even more rare. We report a 76-year-old man who had a previously undiagnosed pheochromocytoma, and presented with the uncommon complication of myocardial infarction. Our high-risk patient was managed with the combination of simultaneous coronary artery bypass grafting and adrenalectomy.