Combined coronary artery bypass grafting and phaeochromocytoma excision

Abstract

SummaryWe 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. Phaeochromocytoma requires careful pre-and intraoperative control of blood pressure to prevent vascular instability induced by unpredictable catecholamine release. It is associated with important risk factors for ischaemic heart disease, such as hypertension, glucose intolerance, hypercholesterolaemia and enhanced coagulation [1], which contribute to the accelerated development of atherosclerosis [2]. Patients with co-existent phaeochromocytoma and coronary artery disease requiring surgical revascularisation are rare, but pose a significant management problem for physicians, surgeons and anaesthetists, in particular with respect to the timing of coronary artery bypass grafting (CABG) and adrenalectomy. We report two cases of phaeochromocytoma with severe coronary artery disease diagnosed during the pre-operative work-up for phaeochromocytoma excision. Both patients were managed successfully with combined CABG and tumour excision, in the first case by laparoscopic adrenalectomy and in the second by laparotomy for a retroperitoneal paraganglioma. Case report 1A 76-year-old female non-smoker with a history of hypercholesterolaemia, hypothyroidism and autoimmune haemolytic anaemia, presented with episodic diaphoresis and nausea for 2 years, worse over the preceding 5 months. She had mild angina and a progressive reduction in exercise tolerance to one flight of stairs, but denied palpitations or symptoms of heart failure. The differential diagnosis included phaeochromocytoma and the patient underwent computed tomography (CT) of the abdomen, where a 4-cm right adrenal mass was found and confirmed to be a phaeochromocytoma by urinary catecholamine assays (adrenaline 1.57 mmol.day )1 (< 0.10), noradrenaline 1.85 lmol.day )1 (< 0.76)). Treatment with phenoxybenzamine was commenced. In view of her cardiac symptoms, she underwent an exercise ECG which was positive and coronary angiography demonstrated severe three vessel disease with normal left ventricular function. Six weeks after the initial diagnosis she proceeded to surgery. At this time she was receiving total daily doses of phenoxybenzamine 120 mg, metoprolol succinate 47.5 mg, simvastatin 40 mg and aspirin 100 mg. Her pre-operative blood pressure was 140 ⁄ 72 mmHg lying and 130 ⁄ 64 mmHg standing, with a heart rate of 65 beats.min )1. After premedication with oral midazolam and radial arterial line insertion, anaesthesia was induced with fentanyl and etomidate, and tracheal intubation was facilitated with rocuronium. Anaesthesia wa...

Coronary Bypass Surgery in the Presence of Metastatic Pheochromocytoma

“…The risk of perioperative mortality during a pheochromocytoma operation can be reduced from 45% to approximately 3% with the judicious use of these treatments . The presence of severe coronary artery disease makes adrenergic blockade even more imperative since even small fluctuations in blood pressure can adversely shift the myocardial supply‐demand balance and cause ischemia . Intraoperatively, the anesthesiologist must be prepared to manage a hypertensive crisis using phentolamine, a short‐acting alpha antagonist.…”

“…A few cases in the literature have described the hemodynamic challenges of performing CABG in a patient undergoing pheochromocytoma resection concurrently . To our knowledge, however, no reports exist of a patient surviving surgical coronary revascularization with metastatic pheochromocytoma.…”

Advantages of Sutureless Aortic Valve in a Patient with Unsuspected Pheochromocytoma

“…Successful CABG both on and off-pump, 3 mitral valve replacement, 4 concurrent CABG with adrenalectomy, 5 and even heart transplant 6 have been described in patients with pheochromocytomas. We described a patient with an unanticipated pheochromocytoma undergoing combined AVR-CABG and postulate that the favorable outcome despite the hypertensive crisis was a result of (1) a high index of suspicion; (2) immediate aggressive treatment of the hypertension bearing in mind its pathophysiology, using phentolamine and labetalol; (3) expeditious surgery with short duration of aortic cross-clamping; and perhaps, (4) the quick implant time of a new sutureless prosthesis.…”

Coronary artery bypass grafting and concomitant excision of chest wall chondrosarcoma

“…Presence of a concomitant phaeochromocytoma in a patient with coronary artery disease requires careful preoperative and intraoperative management of both pathologies in terms of blood pressure control, myocardial protection and haemostasis. To et al reported the first successful cases of combined coronary artery bypass grafting and laparoscopic adrenalectomy for phaeochromocytoma and excision of extra adrenal phaeochromocytoma [ 28 ]. Subsequent successes were described by Garg et al [ 29 ] and Balabaud-Pichon et al [ 30 ].…”