Rapid Onset and Resolution of Cardiogenic Shock in a Patient With Pheochromocytoma

Abstract

A pheochromocytoma is a rare catecholamine-secreting tumor that can be familial or arise sporadically. Its typical presenting features include symptoms of headache, palpitations, and diaphoresis occurring in paroxysms. The classic presenting sign is episodic hypertension, although only in 59% of cases, have evidence of hypertension at diagnosis. 1 There have been a few case reports of patients with pheochromocytoma presenting with cardiogenic shock 2-10 but none with both cardiogenic shock and ventricular tachycardia. Additionally, we are not aware of any case reports of such a rapid decline and then improvement in ejection fraction (EF) as demonstrated in this case. We report the unusual presentation of a patient who developed cardiogenic shock within seconds during the course of a single transthoracic echocardiogram (TTE) only to recover minutes later without intervention. Case ReportA 69-year-old man with type II diabetes mellitus presented with a complaint of a single syncopal episode to an outside institution. The patient was found to have multiple ventricular ectopic beats and frequent runs of nonsustained ventricular tachycardia. The patient was a past smoker but had no personal history of cardiovascular disease or other additional significant medical history. Family history was significant for hypertension and diabetes. The patient was taking metformin and glipizide for his type II diabetes mellitus. The physical examination was significant for orthostasis and an S4 gallop. The remainder of the physical examination was unremarkable. Initial laboratory results demonstrated mildly elevated troponin levels at 0.55 ng ⁄ mL and acute renal failure with a serum creatinine of 1.9 mg ⁄ dL. The patient's hemoglobin concentration was 18.5 g ⁄ dL. There were no other significant laboratory abnormalities. The patient was subsequently transferred to our center for urgent cardiac catheterization for suspected acute coronary syndrome. On transfer, the patient's heart rate was elevated and his blood pressure (BP) was noted to be labile: alternating between severe hypotension and hypertension (Table I).On arrival, an initial electrocardiogram was obtained which showed ventricular ectopics and left ventricular hypertrophy (Figure 1). On telemetry, the patient continued to have multiple episodes of nonsustained ventricular tachycardia (Figure 2). An urgent TTE was performed to assess for regional wall motion abnormalities and to a pericardial effusion that might explain the reason for shock. The initial EF based on the subcostal, short-axis, and parasternal long-axis views was 50% to 55% (Figure 3A and Figure 3B). During the study the EF unexpectedly declined to 5% to 10% ( Figure 3C and Figure 3D) at which time the patient's BP dropped to 68 ⁄ 34 mm Hg and the patient became unresponsive. Fluid resuscitation was initiated and the patient was taken emergently to the cardiac catheterization laboratory.After placement of a right femoral artery sheath, the patient's intraarterial BP was found to be 62⁄ 38 mm Hg. A second left ...

Pheochromocytoma-Induced Inverted Takotsubo-Like Cardiomyopathy Leading to Cardiogenic Shock Successfully Treated With Extracorporeal Membrane Oxygenation

“…However, it may occasionally manifest as noncardiogenic pulmonary edema, 3 acute renal failure, 4 acute myocardial infarction, 5 myocarditis, 6 or other forms of acute cardiomyopathy, 7 –9 with or without cardiogenic shock. 10,11…”

“…However, it may occasionally manifest as noncardiogenic pulmonary edema, 3 acute renal failure, 4 acute myocardial infarction, 5 myocarditis, 6 or other forms of acute cardiomyopathy, [7][8][9] with or without cardiogenic shock. 10,11 Takotsubo cardiomyopathy is characterized by transient left mid-ventricular and often apical dysfunction and ballooning with sparing of basal segments in the absence of acute coronary artery obstruction. 12 Inverted or reverse forms, involving basal segments with preserved contractility of the apex, have more recently been described.…”