Abstract
Perioperative management of pheochromocytoma in the setting of catecholamine-induced heart failure requires careful consideration of hemodynamic optimization and possible mechanical circulatory support. A Jehovah’s Witness patient with catecholamine-induced acutely decompensated heart failure required dependable afterload reduction for a cardio-protective strategy. This was emphasized due to the relative contraindication to perioperative anticoagulation required for mechanical circulatory support. A phenylephrine challenge clearly demonstrated adequate alpha blockade after only 24 hours of phenoxybenzamine treatment. This resulted in advancement of the surgery date. This case also highlights management of beta blockade, volume and salt loading, autologous blood transfusion, and profound post-operative vasoplegia in the setting of cardiogenic shock. Careful attention to hemodynamic optimization and cardio-protective strategies ultimately resulted in positive outcome for this challenging clinical scenario.
Highlights
The pathologic effects of a pheochromocytoma can mimic many cardiovascular syndromes
At the time of writing this report, the patient remains followed-up by the heart failure clinic; he has an improved exercise capacity and is able to hike and chop wood; echocardiograms continues to show an ejection fraction of 30% with diffuse hypo kinesis. His proBNP has fallen from 3566 preoperatively to 172 on most recent labs. This presentation of a patient in acute decompensated heart failure due to a catecholamine-induced cardiomyopathy in the context of a pheochromocytoma provided a challenge in both initial diagnosis and perioperative optimization
Catecholamine-induced acutely decompensated heart failure (ADHF) from pheochromocytoma has been previously described in multiple case reports
Summary
The pathologic effects of a pheochromocytoma can mimic many cardiovascular syndromes. An esmolol infusion (WG Cricial Care LLC, Paramus, New Jersey, USA) was titrated over a 1 hour period from 10 mcg/kg/min to 200 mcg/kg/min with direct observation for mean arterial pressure less than 60 mm Hg, increased work of breathing, or change in mental status The patient tolerated this with no new symptoms and he was started on metoprolol 12.5 mg every six hours (Hospira Inc, Lake Forest, Illinois, USA). Following intra-operative ligation of venous return from the adrenal gland, hypotension ensued Hemodynamic monitoring at this time demonstrated a cardiac index of approximately 2 L/min/ m2 with an epinephrine infusion (Par Pharmaceutical, Chestnut Ridge, New York, United States of America), consistent with a new distributive component on top of the existing cardiogenic shock picture. His proBNP has fallen from 3566 preoperatively to 172 on most recent labs
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