Acute heart failure and transient low voltage in electrocardiogram after massive catecholamine release from a phaeochromocytoma

Catecholamine-Induced Cardiomyopathy in Pheochromocytoma: How to Manage a Rare Complication in a Rare Disease?

Pheochromocytomas and paragangliomas (PHEOs) are rare neuroendocrine tumors. Clinical manifestations include different cardiovascular signs and symptoms, which are related to excessive secretion of catecholamines. Catecholamine-induced cardiomyopathy in PHEO (CICMPP) is a rare but dreaded complication of PHEO. Once patient is diagnosed with this condition, the prognosis is worse and a surgical risk is much higher than expected. This article focuses on how catecholamines affect the heart and the pathophysiologic mechanism of CICMPP. The cardiovascular responses to catecholamine depend mostly on which catecholamine is released as well as the amount of catecholamine that is released. The acute release of norepinephrine and epinephrine from PHEO increases heart rate, systemic vascular resistance, myocardial contractility, and reduces venous compliance. The excessive adrenergic stimulation by catecholamine results in severe vasoconstriction and coronary vasospasm, myocardial ischemia, and subsequently damage, and necrosis. Chronically elevated catecholamine levels lead to significant desensitization of cardiac β-adrenoceptors. The increased levels of the enzyme β-adrenoceptors kinase (βARK) in the heart seems to mediate these biochemical and physiological changes that are consistently correlated with attenuated responsiveness to catecholamine stimulation. Through these mechanisms different types of cardiomyopathy (CMP) can be formed. This review discusses extensively the 3 types of cardiomyopathies that can be present in a PHEO patient. It also provides the clinical presentation and diagnostic and therapeutic algorithm in managing patients with CICMPP.

Transient attenuation of the amplitude of the QRS complexes in the diagnosis of Takotsubo syndrome

BACKGROUND AND OBJECTIVES

Currently, there are no specific diagnostic electrocardiogram (ECG) signs for Takotsubo syndrome (TTS) to differentiate it from acute coronary syndromes (ACS). Myocardial oedema has been detected by cardiac magnetic resonance imaging in patients with TTS. Recently it has been postulated that myocardial oedema may be the cause of low QRS voltage (LQRSV) in the admission ECG and attenuation of the amplitude of the QRS complexes (AAQRS) in serial ECGs, noted in a few published cases of patients with TTS. The objective of this study was to evaluate whether the admission ECG of patients with documented TTS reveals LQRSV and whether AAQRS is found when serial ECGs are compared in such patients.

METHODS

This study evaluated the prevalence of LQRSV in the admission ECG and AAQRS in serial ECGs in patients with TTS. ECGs of 368 patients with TTS from published reports in the international literature were evaluated for LQRSV (≤5 mm in limb leads and/or ≤10 mm in precordial leads) and AAQRS in serial ECGs.

RESULTS

LQRSV was seen in 91.5% of 200 patients with TTS and one ECG, with a distribution of 49.0, 42.8, 51.0, 52.0, and 46.9%, in lead aVR, and inferior, anterior, lateral, and high lateral ECG lead groups, respectively. AAQRS was seen in 93.5% of 168 patients with TTS and two or more ECGs, with a distribution of 78.3, 74.5, 60.1, 70.7, and 74.5% in lead aVR, and inferior, anterior, lateral, and high lateral ECG lead groups, respectively.

CONCLUSIONS

LQRSV and AAQRS are highly prevalent ECG signs in patients with TTS, and should be useful in aiding in its diagnosis and differentiation from ACS, on first contact with the patient on admission to the hospital, and the ensuing 24 hours, in conjunction with echocardiography and coronary arteriography.

Reduced myocardial contractility assessed by tissue Doppler echocardiography is associated with increased risk during adrenal surgery of patients with pheochromocytoma: report of a preliminary study

BACKGROUND

Depressed myocardial contractility, although rarely reported in pheochromocytoma, might be underestimated. It may be a determinant of perioperative risk during adrenal surgery.

METHODS

We prospectively studied consecutive patients with pheochromocytoma; myocardial function examined by standard and tissue Doppler echocardiography was compared with matched control subjects. The incidence of hemodynamic collapse during adrenal surgery was measured.

RESULTS

A total of 15 patients were included (8 men, 46 [17] years, hypertension in 10). All but one had a normal left ventricular ejection fraction. However, compared with control subjects, they had a depressed systolic strain rate (SR) (1.8 [2.1] vs 4.1 [2.2] s(-1), P = .007). Furthermore, 6 of 8 patients with systolic SR less than 2 s(-1) experienced intraoperative collapse, versus 1 of 7 with SR greater than 2 s(-1) (P = .041). No association was observed with other variables.

CONCLUSIONS

Patients with pheochromocytoma may have depressed myocardial contractility detected by tissue Doppler echocardiography despite a normal standard echocardiogram. A systolic SR less than 2 s(-1) was associated with an increased risk of perioperative collapse.

Le phéochromocytome comme cause inhabituelle de choc cardiogénique

The authors reported a case involving a young patient with a cardiogenic shock associated to an acute pulmonary oedema. According to the seriousness of the shock, an external ventricular assist device (VAD) was initially inserted and replaced thereafter because of the cardiovascular instability, by an external pneumatic biventricular assist device. A cardiogenic shock induced by an acute adrenergic myocarditis due to a phaeochromocytoma was diagnosed. The patient was weaned from the VAD on day 84 and was scheduled for elective surgery of the phaeochromocytoma on day 93. The authors discussed the time of the surgery according to the anticoagulation therapy necessary to the VAD and the necessary caution taken if a cardiogenic shock appeared around surgery.